Split (1)

train · 26.9k rows

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46,066	117,825	37497+58130	Discharge summary	report+addendum	Admission Date: [2199-2-8] Discharge Date: [2199-3-1] Date of Birth: [2126-1-14] Sex: F Service: CARDIOTHORACIC Allergies: Keflex / Statins-Hmg-Coa Reductase Inhibitors / Sulfasalazine Attending:[First Name3 (LF) 165] Chief Complaint: loss of consiousness Major Surgical or Invasive Procedure: left and right heart catheterization, coronary angiogram redo sternotomy, aortic valve replacement (21mm CE Magma pericardial) History of Present Illness: The patient 73 year old white female was admitted to [Hospital1 18] on [2199-2-8] after being found collapsed in her kitchen at home. Her husband reportedly left for work at approximately 6:30 am on [2-8]. He then called his wife at 8:30 am to relay a message, and when she did not answer the phone, he became concerned. He drove home and found her unconscious on the kitchen floor. Per report, he did not notice any abnormal movements, incontinence, or tongue biting. When the paramedics arrived, she had GCS score of 5 and was intubated and transferred to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. There, she had a head CT that was concerning for possible [Last Name (LF) ], [First Name3 (LF) ] she was transferred to [Hospital1 18] for further care. On arrival to [Hospital1 18], she was admitted to the trauma ICU, where she was treated empirically for seizures with phenytoin. She had a CT/CTA head, which was negative, and subsequent MRI showed a small area of [Hospital1 ] but no major bleed. Given the fact that the previous CTA was normal, it was deduced that the subarachnoid hemorrhage was traumatic rather than the cause of her collapse. She was extubated on [2-9] and was then transferred to the neurology service. [2-10] patient without complaints, VS notable for SBP range: 160-197/90-100s, HRs: 90-100s, On [2-11] at approximately 5 am, when she became acutely dyspneic. She was given Lasix 10 mg IV x1 and Morphine, and EKG showed new ST depressions in V4-V6. Cardiology was called, and she was started on a heparin gtt. Since this time, she has received 2 more doses of Lasix IV and was started on albuterol nebulizations for increased dyspnea. . Currently, the patient is short of breath and states that she feels like she is "drowning." Otherwise, she has no new complaints. Cycled enzymes at that time were positive: CK: 1132 MB: 29 MBI: 2.6 Trop-T: 0.90. . . Past Medical History: DM HTN Liver CA CABG x5 (4yrs ago) Social History: She is married, and has two children, a son who lives in [Name (NI) 531] and a daughter who lives locally. She has a three-pack per day x20 year history of smoking, quitting in [2177]. She previously was employed making fuses, but has not worked since about the time when she was 40 years old Family History: Her father died at a young age of a large ulcer and was an alcoholic. Her mother died at the age of 86 of an MI and also had diabetes. She has a brother who also has issues with low blood counts; family is not sure of the diagnosis. Her brother also has diabetes Physical Exam: On Admission to Cardiology Service: VS: T 99.0, BP 152/90, P 87, R 18, O2 97% on 3L GENERAL - Elderly woman, pleasant, using excessory muscles in obvious respiratory discomfort. HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry mucus membranes - clotted blood in mouth, OP clear NECK - supple, no thyromegaly, no carotid bruits, JVD ~10 cm CV: RRR, III/[Doctor First Name 81] holosystolic murmur which radiates to to the carotids and axilla, no peripheral edema LUNGS - Diffuse expiratory wheezes bilaterally in all lung fields, decreased bs at bilateral bases. ABDOMEN - soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses SKIN - no rashes or lesions NEURO - awake, A&Ox1 (to person only), CNs II-XII grossly intact, muscle strength 5/5 throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady . On Discharge: VS: ; weight: GENERAL - Elderly woman, pleasant, using excessory muscles in obvious respiratory discomfort. HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry mucus membranes - clotted blood in mouth, OP clear NECK - supple, no thyromegaly, no carotid bruits, CV: RRR, III/[Doctor First Name 81] holosystolic murmur which radiates to to the carotids and axilla, no peripheral edema LUNGS - ABDOMEN - soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses SKIN - no rashes or lesions NEURO - awake, A&Ox1 (to person only), CNs II-XII grossly intact, muscle strength 5/5 throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady Pertinent Results: TTE: The left atrium is mildly dilated. The right atrial pressure is indeterminate. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The estimated cardiac index is normal (>=2.5L/min/m2). 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 are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Trace aortic regurgitation is seen. The mitral valve leaflets and annulus are moderately thickened. There is no mitral stenosis. The high mean gradient is likely due to mitral regurgitation. Moderate to severe (3+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with low normal systolic function. Severe aortic valve stenosis. Moderate to severe mitral regurgitation. Pulmonary artery systolic hypertensio . MRI brain [2199-2-9]: IMPRESSION: No evidence of acute infarct or enhancing brain lesion. Subtle area of hyperintensity in the right posterior frontal sulcus, both on FLAIR and diffusion images likely represents a small area of subarachnoid blood related to recent trauma. No evidence of acute intraparenchymal hemorrhage seen. Brain atrophy noted [2199-2-8]: CT ANGIOGRAPHY HEAD: CT angiography of the head demonstrates exuberant calcification and diffuse atherosclerotic disease involving the left distal vertebral artery in the V4 segment. The basilar artery and the right distal vertebral artery appear patent. In the anterior circulation mild irregularity of the vascular structures are seen in the anterior circulation due to atherosclerotic disease without high-grade stenosis. No vascular occlusion is identified. IMPRESSION: 1. CT angiography of the neck demonstrate diffuse atherosclerotic disease involving the left common carotid artery in the neck with irregularity of the arterial margin. Bilateral widely patent and proximal internal carotid arteries are noted which could be related to previous surgery. Clinical correlation recommended. No evidence of high-grade stenosis in the neck. 2. CT angiography of the head demonstrates exuberant calcification and diffuse atherosclerotic disease involving the distal left vertebral artery. Mild atherosclerotic disease seen in the anterior circulation involving middle cerebral arteries. 3. A small wedge-shaped opacity seen posteriorly in the left upper lung could be due to atelectasis, but clinical correlation recommended. 4. An aberrant right subclavian artery is incidentally noted. CT C-spine: [2199-2-8]: IMPRESSION: 1. No evidence of fracture or malalignment. 2. Multilevel degenerative changes including moderate-to-severe central canal narrowing secondary to disc osteophyte complexes at C4-5 and C5-6. Narrowing of the central spinal canal predisposes to spinal cord injury in the setting of trauma. MR is more sensitive than CT for evaluation of the spinal cord. 3. Sub-cm left thyroid nodule with adjacent calcification. Clinical correlation recommended, and consider non-emergent ultrasound for further evaluation. Labs: [2199-2-8] 01:30PM ALT(SGPT)-62* AST(SGOT)-75* CK(CPK)-178 ALK PHOS-209* TOT BILI-1.0 [2199-2-8] 01:30PM CK-MB-6 cTropnT-0.03* [2199-2-8] 01:30PM WBC-9.5 RBC-3.80* HGB-12.2 HCT-37.2 MCV-98 MCH-32.1* MCHC-32.8 RDW-18.2* [2199-2-8] 01:30PM NEUTS-87.7* LYMPHS-7.2* MONOS-4.8 EOS-0.2 BASOS-0.2 [2199-2-8] 01:30PM PLT SMR-LOW PLT COUNT-83* [2199-2-8] 01:30PM PT-13.2 PTT-29.5 INR(PT)-1.1 [2199-2-8] 01:30PM GLUCOSE-145* UREA N-32* CREAT-1.2* SODIUM-141 POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-22 ANION GAP-16 [2199-2-8] 01:30PM CALCIUM-9.3 PHOSPHATE-2.2* MAGNESIUM-1.9 [2199-2-8] 01:30PM ALT(SGPT)-62* AST(SGOT)-75* CK(CPK)-178 ALK PHOS-209* TOT BILI-1.0 [2199-2-8] 01:30PM CK-MB-6 cTropnT-0.03* [2199-2-8] 06:29PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2199-2-8] 01:30PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG Brief Hospital Course: On arrival to [Hospital1 18], she was admitted to the trauma ICU, where she was treated empirically for seizures with phenytoin. She had a CT/CTA head, which was negative, and subsequent MRI showed a small area of [Hospital1 ] but no major bleed. Given the fact that the previous CTA was normal, it was deduced that the subarachnoid hemorrhage was traumatic rather than the cause of her collapse. She was extubated on [2-9] and was then transferred to the neurology service. [2-10] patient without complaints, VS notable for SBP range: 160-197/90-100s, HRs: 90-100s, On [2-11] at approximately 5 am, she became acutely dyspneic. She was given Lasix 10 mg IV x1 and Morphine, and EKG showed new ST depressions in V4-V6. Cardiology was called, and she was started on a Heparin infusion. Subsequent cardiac work up included catheterization to reveal patent LIMA to LAD and vein grafts to the OM and RCA and right heart pressures were normal. Aortic stenosis was present with valve area of 0.8-1cm squared, moderate MR. She was referred for redo sternotomy and aortic valve replacement. On [2-19] she went to the Operating Room where she underwent redo sternotomy/ Aortic valve replacement with a size 21-mm [Last Name (un) 3843]- [Doctor Last Name ] Magna tissue valve with Dr.[First Name (STitle) ]. Please refer to operative report for further details. Cardiopulmonary Bypass Time= 81 minutes. Cross clamp time=64 minutes. She tolerated the procedure well and was transferred to the CVICU intubated and sedated in critical but stable condition. She weaned and extubated easily,all lines and drains were discontinued in a timely fashion. She had asysytole underneath temporary pacing wires and she was atrially paced. Electrophysiology was consulted and on [2199-2-20] at 06:43:27 where it was evident that there was no intrinsic rhythm present. [2199-2-25] Cardiology placed a dual chamber [Company 1543] PPM. She tolerated the procedure well and epicardial wires were removed. EP interrogated the PPM the following day. Physical Therapy was consulted for evaluation of strength and mobility. The remainder of her hospital course was essentially uneventful. On POD# [9-24] she was cleared for discharge to [Hospital3 ] in [Location (un) ]. All follow up appointments were advised. Medications on Admission: Medications (as per OSH sheet with no doses listed); -lantus -celexa -lisinopril -isosorbide -toprol -aspirin -mvt -iron -humulog -epogen Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day: until lower extremity edema resolved. 3. Combivent 18-103 mcg/Actuation Aerosol Sig: [12-23] Inhalation four times a day as needed for shortness of breath or wheezing. 4. multivitamin Tablet Sig: One (1) Tablet PO once a day. 5. iron 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 7. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheeze. 14. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 15. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 18. Insulin- regular Insulin per sliding scale finger stick before meals and at bedtime. Discharge Disposition: Extended Care Facility: [Hospital1 ] Pavilion - [Location (un) ] Discharge Diagnosis: Aortic Stenosis s/p AVR Atrial Fibrillation - s/p permanent DDD pacer on [2199-2-25] Hypertension Urinary Tract Infection subarachnoid hemorrhage s/p bilateral carotid endarterectomies s/p bilateral cataract extractions non insulin dependent diabetes mellitus h/o hepatocellular carcinoma s/p chemoembolization of liver tumor chronic thrombocytopenia hypertension hyperlipidemia Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Edema 1+ LE 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 for sternal precautions No lifting or pulling anything weighing more than five pounds using left arm due to pacemaker insertion Do NOT raise your left elbow above the height of your shoulder due to pacemaker insertion. Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon:Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 170]on [2199-3-4] 2:00 Please call to schedule appointments with: Primary Care: DrGavin Little in [3-26] weeks ([Telephone/Fax (1) 84226] Cardiologist:Dr.[Last Name (STitle) 77919] in [2-22] weeks([Telephone/Fax (1) 65733]) Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2199-3-1] Name: [Known lastname 13314],[Known firstname 300] Unit No: [Numeric Identifier 13315] Admission Date: [2199-2-8] Discharge Date: [2199-3-1] Date of Birth: [2126-1-14] Sex: F Service: CARDIOTHORACIC Allergies: Keflex / Statins-Hmg-Coa Reductase Inhibitors / Sulfasalazine Attending:[First Name3 (LF) 265] Addendum: [Company 1331] DDD pacer placed on [2199-2-25] 4076- 52cm; 4076- 45cm serial number:[Serial Number 13316]H Discharge Disposition: Extended Care Facility: [Hospital1 ] Pavilion - [Location (un) 4415] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 266] Completed by:[2199-3-1]	[ "410.71", "276.0", "428.21", "584.9", "599.0", "397.0", "414.01", "426.0", "E888.9", "585.9", "403.90", "287.5", "852.06", "396.2", "428.0", "155.0", "238.75", "041.4", "348.30", "416.8", "250.00" ]	icd9cm	[ [ [] ] ]	[ "35.21", "37.72", "37.23", "96.71", "37.83", "39.61", "88.56" ]	icd9pcs	[ [ [] ] ]	16597, 16795	9398, 11748	347, 476	14093, 14266	4786, 9375	15410, 16574	2849, 3113		11937, 13568		13687, 14072		11774, 11914				14290, 15387													3128, 4025																	4039, 4767									286, 309							504, 2456																	2478, 2514	2530, 2833
14,922	120,064	43091+43125	Discharge summary	report+report	Admission Date: [2125-3-28] Discharge Date: [2125-4-1] Service: Medicine CHIEF COMPLAINT: Dyspnea. HISTORY OF PRESENT ILLNESS: This 88 year old male with cardiomyopathy, systolic congestive heart failure with an ejection fraction of 20%, hypertension and a history of atrial fibrillation/atrial flutter, status post ablation who presents with progressive dyspnea and lower extremity edema, three weeks after having a right knee operation at [Hospital3 1196] with a discharge to an acute rehabilitation facility. Several of the patient's medications were discontinued upon discharge including his ACE inhibitor and Lasix. The patient complained of increasing dyspnea on exertion previously a very active person for his age, walking two to three miles a day. Over the past several weeks he has noted difficulty with walking either short distances or up stairs. He has also noted increasing lower extremity edema bilaterally with slightly more edema on the right leg. He has not had any chest pain, palpitations, jaw pain or arm pain. He has had occasional dry cough and has noted a several pound weight gain over the past few days. Of note, prior to his orthopedic surgery the patient had a MIBI stress test that revealed a substantial anterior reversible defect, mild to moderate aortic stenosis with an ejection fraction of 20 to 25%. PAST MEDICAL HISTORY: Cardiomyopathy, congestive heart failure with an ejection fraction of 20 to 25%, recent MIBI stress test showing a substantial reversible anterior defect. History of atrial flutter status post ablation and pacer placement, hypertension, hyperlipidemia, right knee orthopedic surgery at [Hospital3 1196]. Renal mass on computerized tomography scan. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Spironolactone 12.5 mg, this medication was being held, Lisinopril 5 mg daily, Lopressor 12.5 mg b.i.d., Lasix 10 mg daily, Amiodarone 200 mg daily, Coumadin 1.5 mg daily, Lipitor 10 mg daily. SOCIAL HISTORY: The patient is married, does not smoke, does not drink alcohol. PHYSICAL EXAMINATION: Temperature 97.7, heart rate 81, blood pressure 100/47, respiratory rate 12, oxygen saturation 95% on room air. General: In no acute distress, pleasant. Head, eyes, ears, nose and throat, pupils equal, round and reactive to light. Neck: Clear oropharynx. Jugulovenous distension approximately 10 cm. Cardiovascular examination, regular rate and rhythm with II/VI systolic ejection murmur at the left upper sternal border. Lungs, occasional expiratory wheezes, baseline basilar crackles, decreased breath sounds at the bases, left greater than right. Abdomen, positive bowel sounds, soft, nontender, nondistended. Extremities, 1+ right lower extremity edema, trace to 1+ left lower extremity edema. Neurologic examination, alert and oriented, cranial nerves III through XII intact bilaterally. Strength, [5-16] bilaterally in the upper and lower extremities. LABORATORY DATA: On admission white blood cell count 7.1, hematocrit 35.2, platelets 216, sodium 141, potassium 4.3, chloride 109, bicarbonate 22, BUN 43, creatinine 1.5, glucose 11, INR 2.7. Urinalysis was negative for urinary tract infection. Chest x-ray showed bilateral pleural effusions and pulmonary edema consistent with stable cardiac failure. There were new left lower lobe opacities which could represent atelectasis versus pneumonia. Electrocardiogram showed AV paced rhythm, no significant change since previous echocardiogram, moderately dilated left atrium, mild symmetric left ventricular hypertrophy with a dilated left ventricle, severely depressed left ventricular systolic function with an ejection fraction of 20 to 25%. Global hypokinesis and depressed right ventricular systolic function, 2+ mitral regurgitation, 2+ tricuspid regurgitation, moderate pulmonary artery systolic hypertension. HOSPITAL COURSE: 1. Congestive heart failure - On admission, the patient was felt to be clinically in congestive heart failure. The patient was placed back on Lasix and his Lisinopril was increased. He was continued on his Toprol XL as he had baseline of chronic renal failure with a slightly elevated creatinine. Cardiology was consulted for initiation of a Nesreotide drip for renal protective diuresis. The patient was slowly diuresed to approximately 5 to 700 cc negative per day, on low dose Natrecor and small amounts of intravenous Lasix. In addition Cardiology was consulted for a cardiac catheterization as the patient had recently undergone a MIBI stress test which showed a substantial reversible anterior wall defect. 2. Atrial fibrillation - The patient has a history of atrial fibrillation/atrial flutter status post ablation. He is now AV paced. The patient was therapeutic on Coumadin on admission. His Coumadin was held for cardiac catheterization. 3. Lung findings - The patient had increased interstitial markings seen on previous chest x-rays. There was a question of whether or not this was related to Amiodarone toxicity. The patient reported to have unremarkable pulmonary function tests. However, at some point the patient should undergo a baseline computerized axial tomography scan of the chest. 4. Renal mass - The patient had a 2.9 cm renal mass seen on the previous computerized axial tomography scan. The patient will need a repeat abdominal computerized axial tomography scan in four to six weeks to further evaluate this renal mass. The remainder of the hospital course will be dictated by the covering surgical intern. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 26586] Dictated By:[Last Name (NamePattern1) 9609] MEDQUIST36 D: [2125-4-1] 17:45 T: [2125-4-1] 19:32 JOB#: [Job Number ] Admission Date: [2125-3-28] Discharge Date: [2125-4-13] Service: GENERAL SURGERY HISTORY OF THE PRESENT ILLNESS: The patient is an unfortunate 88-year-old gentleman with a past medical history significant for cardiomyopathy and severe systolic congestive heart failure with an ejection fraction of 20%, hypertension, and a history of atrial fibrillation and atrial flutter status post ablation who presented to the Medical Service on [2125-3-28] with progressive dyspnea and lower extremity edema three weeks after having a right knee operation at [Hospital3 1196] upon being discharged to an acute rehabilitation facility. He was admitted to the Medical Intensive Care Unit for several days with respiratory failure and congestive heart failure. The patient had troponin leak during this period. He was recovering, actively diuresing well when his clinical picture worsened over the course of [1-4] hours. The patient's white blood cell count rose from the normal level to about 20,000 prior to his operation. He was noted to have an abdominal examination that progressively worsened and became more distended and tender to palpation. He became fluid requiring, pressor requiring, and an emergent surgical consult was obtained. The patient was evaluated by the General Surgical Service and felt to have an acute abdomen. At this point, he was quite ..................... His grave prognosis was discussed in detail with the wife and multiple family members and the likelihood of having some ischemic or dead bowel within his abdominal cavity was very high and the family elected to proceed with an exploratory laparotomy for definitive diagnosis and therapy. Once again, the poor prognosis was emphasized to the family but as there were not many options for this gentleman at that time other than making him CMO and continued medical therapy, the decision unanimously was made by the family in terms of having him undergo this exploratory laparotomy. After adequate consents were signed and obtained, the patient was taken to the Operating Room on [2125-4-8] by Dr. [First Name (STitle) 2819]. Upon performing an exploratory laparotomy, necrotic colon extending from the cecum all the way to the proximal descending colon was encountered. He underwent a subtotal colectomy with a Hartmann's procedure as well and an end-ileostomy and a gastrostomy tube placement. The patient was extremely labile during the procedure requiring multiple pressors in order to keep his systolic blood pressure. Immediately postoperatively, he was transferred to the Intensive Care Unit in fair to critical condition. Since postoperative day number one, the patient failed to wean off the pressors that he was receiving in order to keep his systolic blood pressure and his renal function progressively deteriorated but he continued to make urine. All this time he was unable to be weaned off the ventilator and progressively deteriorated requiring more and more ventilatory support, eventually developing a pneumonia. During all this time he was kept on broad spectrum antibiotics including vancomycin, levofloxacin, and Flagyl and his medical management was maximized while he was in the Surgical Intensive Care Unit with collaboration of Cardiology as well as the Renal and ID Team. Following Cardiology recommendations and in an effort to improve his hemodynamics, on postoperative day number two, the patient was started on milrinone in an effort to increase his cardiac performance. Unfortunately, the patient developed a sustained V tach that resolved after a 43 beat run, ultimately requiring to be placed on an Amiodarone drip. A family meeting was carried out with the family and once again the really poor prognosis as well as the critical condition was explained in detail to the family members but at that time decided to make the patient a DNR but continue full support medically. By [2125-4-13], postoperative day number five, it was clear the this gentleman was progressively worsening and deteriorating. He continued to require pressors in order to keep a minimal systolic blood pressure and his renal function was worsening by the day. On the morning of this same postoperative day number five, he dropped his pressure to the 80s requiring the addition of a new pressor to keep him up around 50. At that time, the family was informed and they requested to have a new family meeting to further discuss management on this patient. The family meeting was held in the presence of the residents of the surgical team, the attending, as well as the ICU staff and upon explaining once again the seriousness and the critical condition that he was at that time, the family decided to make him comfort measures only and not proceed with any further medical therapy. Pressor support was withdrawn and he was kept on a Fentanyl drip, making sure that he was comfortable. Shortly after these measures were undertaken, the patient underwent a cardiorespiratory arrest. He was not resuscitated. He was pronounced dead at 4:00 p.m. on [2125-4-13]. The family was present at the time and they declined a postmortem examination. Dr. [First Name (STitle) 2819] as well as the medicine attending and PCPs were notified of this death. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 19318] Dictated By:[Last Name (NamePattern4) 26544] MEDQUIST36 D: [2125-4-13] 07:40 T: [2125-4-13] 22:32 JOB#: [Job Number 92970]	[ "584.9", "427.31", "V66.7", "785.51", "428.0", "403.91", "557.0", "518.81", "786.3" ]	icd9cm	[ [ [] ] ]	[ "00.13", "46.21", "96.04", "96.72", "33.22", "54.4", "43.19", "96.6", "45.79", "99.15", "45.95" ]	icd9pcs	[ [ [] ] ]													1812, 2006	3921, 11410																														2111, 3903												111, 121							150, 1370																	1393, 1785	2023, 2088
66,295	190,602	41454	Discharge summary	report	Admission Date: [2160-7-1] Discharge Date: [2160-7-13] Date of Birth: [2099-9-27] Sex: F Service: OME The patient was on the Biologic Service. HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old female with metastatic mucosal melanoma admitted today to begin cycle 1 week 1 high-dose IL-2 therapy. Her oncologic history began in [2159-9-26] when she started to have rectal pain initially thought to be hemorrhoids. She began over-the-counter agents but did not get relief and was eventually referred to a surgeon who felt this was an anal fissure in combination with hemorrhoids for which she recommended steroids and over-the-counter remedies. On [2160-3-10] she underwent surgery with a rectal mass noted. Biopsy revealed melanoma with tumor cells staining positive for S100, Melan-A, HMB45 anti-tyrosinase. Torso CT revealed left hilar adenopathy, two indeterminate densities at the right hemithorax and numerous hepatic lesions highly suggestive of metastatic disease. On [2160-4-11] she started temozolomide 5 days on and 23 days off with radiation to the rectal region for pain relief. She received 4 of 5 planned fractions. She completed 2 cycles of Temodar in [Month (only) 116] with torso CT showing interval progression in the perirectal adenopathy and liver lesions. She was referred here to discuss treatment options and high-dose IL-2 was recommended. Her nuclear stress test revealed no EKG changes but there was a perfusion defect. It was unclear if this was artifact so she underwent cardiac catheterization on [2160-6-30] revealing a 30% to 40% stenosis of the LAD felt to be hemodynamically insignificant. She passed eligibility testing and is now admitted to begin cycle 1 week 1 high-dose IL-2 therapy. PAST MEDICAL HISTORY: Melanoma as above, osteopenia, anxiety disorder with insomnia, status post TAH-BSO, status post laparoscopic cholecystectomy in [2154], history of low blood pressure. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Married with 3 daughters. Lives in [State 1727] where she owns a restaurant. Prior heavy smoking 1 pack per day x30 years, currently smokes 6 to 7 cigarettes per day. MEDICATIONS: Fentanyl 50 mcg topically daily, ondansetron 8 mg p.o. t.i.d. p.r.n. nausea, multivitamin tablet daily, senna C 3 tablets at bedtime, Prozac 20 mg daily. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: GENERAL: Well-appearing female in no acute distress. Performance status 1. VITAL SIGNS: 98.1, 85, 18, 96/66, O2 sat 95% on room air. HEENT: Normocephalic, atraumatic. Sclerae anicteric. Moist oral mucosa without lesions. LYMPH NODES: No cervical, supraclavicular or bilateral axillary lymphadenopathy. HEART: Regular rate and rhythm, S1/S2. CHEST: Clear. ABDOMEN: Rounded, soft, nontender. EXTREMITIES: No edema. SKIN: Intact. NEUROLOGIC EXAM: Nonfocal. ADMISSION LABS: WBC 10.1, hemoglobin 13.4, hematocrit 40.1, platelet count 335,000, INR 1.1. BUN 12, creatinine 0.6, sodium 138, potassium 3.7, chloride 100, CO2 27, glucose 119, ALT 33, AST 29, CK 37, total bilirubin 0.3, albumin 4.5, calcium 9.4, phosphorus 3.0, magnesium 2.0. HOSPITAL COURSE: The patient was admitted and underwent central line placement to begin therapy. Her admission weight was 66.9 kg and she received interleukin-2 600,000 international units per kilo equalling 40.3 million units IV q. 8 hours x14 potential doses. During this week she received 9 of 14 doses with doses held related to development of shock and toxic encephalopathy. Her course was also complicated by acute pulmonary edema with respiratory distress syndrome. Hypotension was initially noted on treatment day 4 with initial response to a fluid bolus. Hypotension was related to capillary leak syndrome from IL-2 therapy. She developed recurrent hypotension, this time requiring the initiation of vasopressor therapy with Neo- Synephrine. Continuous blood pressure bedside and central telemetry monitoring were instituted. No cardiac arrhythmias were noted. IL-2 therapy was held while on Neo-Synephrine. On treatment day 5 she was noted to be lethargic and confused consistent with toxic encephalopathy. Frequent safety checks were instituted per nursing policy. IL-2 therapy was held throughout that day given mental status changes. On treatment day 6 she was tachypneic with hypoxia and chest x- ray confirmed acute pulmonary edema. She initially responded to nebs and Lasix but again became tachypnea with hypoxia requiring an ICU transfer. In addition she became hypotensive at that point requiring initiation of Neo- Synephrine blood pressure support again. In the ICU she was treated with BiPAP and serial cardiac enzymes were done to rule out cardiac source which were negative. Echo revealed a normal LVEF. She was aggressively diuresed and ruled out for an infection. She was eventually transferred back to the floor on [2160-7-9] where she initiated physical therapy. She had some borderline oxygen saturations and was thus sent home with home oxygen therapy on [2160-7-13] after otherwise recovering from treatment. Other side effects from IL-2 this week included nausea and vomiting improved with antiemetic therapy; diarrhea; fatigue and development of an erythematous pruritic skin rash. Her rectal pain was managed with fentanyl patch, p.r.n. oxycodone and topical lidocaine. During this week she developed acute renal failure with a peak creatinine of 1.3 improved to 0.4 at the time of discharge. She had associated oliguria and mild metabolic acidosis noted with a minimum bicarb of 18. She was treated with bicarbonate replacement intravenously. Electrolytes were monitored and repleted per protocol. Strict I & Os were maintained. IV fluids were significantly decreased given acute pulmonary edema in the setting of renal failure. She developed transaminitis with a peak ALT of 234 and a peak AST of 151, both improved within normal limits at the time of discharge. She developed hyperbilirubinemia with a peak bilirubin of 2.6 improved to normal at the time of discharge. She was anemic without need for packed red blood cell transfusion. She developed mild thrombocytopenia with platelet count low of 132,000 without evidence of bleeding. She had no coagulopathy or myocarditis noted. By [2160-7-13] she had recovered from side effects to allow for discharge to home. CONDITION ON DISCHARGE: She was alert, oriented and ambulatory. DISCHARGE STATUS: To home with her family. DISCHARGE DIAGNOSIS: Metastatic melanoma status post cycle 1 week 1 high-dose IL-2 therapy complicated by shock, acute pulmonary edema and acute renal failure. DISCHARGE MEDICATIONS: Tylenol 320 to 650 mg t.i.d. p.r.n. pain, albuterol inhaler 1 to 2 puffs q.i.d., Sarna lotion topically, Benadryl 25 to 50 mg q.i.d. p.r.n. pruritus, Lomotil 1 to 2 tabs q.i.d. p.r.n. loose stools, Colace 100 mg t.i.d. p.r.n. constipation, fentanyl patch 50 mcg topically q. 72 hours, Prozac 20 mg p.o. daily, glycerin suppository p.r.n. constipation, lidocaine 5% ointment topically to perirectal area p.r.n. pain, Imodium 2 to 4 mg q.i.d. p.r.n. diarrhea, lorazepam 0.5 to 1 mg t.i.d. p.r.n. nausea/vomiting, oxycodone 5 to 10 mg q. 4 hours p.r.n. pain, Compazine 10 mg q.i.d. p.r.n. nausea/vomiting, ranitidine 150 mg p.o. b.i.d. p.r.n. heartburn, senna 1 to 2 tablets t.i.d. p.r.n. constipation, Eucerin cream topically. FOLLOW-UP PLANS: The patient will return on [2160-7-21] for week number 2 of therapy. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD [MD Number(1) 7782] Dictated By:[Last Name (NamePattern1) 18853] MEDQUIST36 D: [2160-8-22] 16:26:26 T: [2160-8-24] 12:28:33 Job#: [Job Number 90175] cc:[Numeric Identifier 90176] [Name6 (MD) 90177] [Name8 (MD) ], M.D. The [Hospital 90178] Medical Center [Street Address(2) 90179] [Location (un) ], [Numeric Identifier 90180]	[ "197.0", "518.81", "292.81", "288.60", "287.49", "E933.1", "787.01", "780.52", "V88.01", "693.0", "518.4", "584.9", "733.90", "276.8", "276.0", "276.2", "V10.06", "300.00", "276.3", "491.21", "300.4", "458.29", "V15.3", "285.3", "197.7", "V10.82", "782.4", "338.3", "V66.7", "154.1", "275.3", "349.82", "785.59", "401.9", "196.5", "196.1", "V58.11", "564.09", "V15.82" ]	icd9cm	[ [ [] ] ]	[ "00.15", "38.93" ]	icd9pcs	[ [ [] ] ]							2405, 2423		6744, 7470		6580, 6720			3220, 6447																														2446, 2890					7488, 8038														206, 1794						2936, 3202									2908, 2919		1817, 2027	2044, 2388	6472, 6558
53,863	136,210	42523	Discharge summary	report	Admission Date: [2161-2-21] Discharge Date: [2161-3-6] Date of Birth: [2083-6-24] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2712] Chief Complaint: found down Major Surgical or Invasive Procedure: Intubation and extubation Central Line placement and removal PICC line placement History of Present Illness: 77 yo F with no known medical history found down in bathroom in her home. Family had not heard from patient in several days, called the neighbor and asked them to check in on her. Neighbor had hard time getting into apartment and called EMS. EMS found patient in a dirty home, cluttered, "hoarding environment" and found pt lying on bathroom floor on right side with vacuum on top of her. She was awake, able to tell them she had pain everywhere. GCS 13 per EMS. Went to [Hospital3 4107] first, had negative head and cspine CT. Plain films of lower extremities negative, she was then transferred to [Hospital1 18] for further workup. In [Name (NI) ], Pt noted to have numerous pressure ulcers, specifically on the right side. Has dark urine. In the ED inital vitals were, BP 70s--> given 2 L, intubated her for hypotension and minimally responsive mental state. T 34.5, 115, 99/65, 100%v Vt 450, r14, peep5, 50% Fi02. She was found to be in Afib with RVR, hr 166 given dilt 10mg x2-->119. Pt wth hypothermia, T 34.5, had barehugger. Concern for sepsis and given zosyn here, vanc + rocephin at OSH. Was started on levophed 0.09, sedated with fent and midaz. Given 5 L warmed NS. Had R IJ placed. CT torso performed in ED. Family says: no allergies, full code, has ho right knee surgery and right hip surgery? Labs notable for positive UA, INR 1.7, PTT 22, WBC 17, HCT 45, PLT 386. P 9.1, Mg 4.4, Ca 8.5. CK 450. Na 169, K 5.4, Cl 127, Bicarrb 19, BUN 255, Cr 4.0, Gluc 167. AG 23. Trop 0.03. Lacate 3.5. Albumin 3.1, ALT 34, AST 30, AP 78, [Initials (NamePattern4) ] [Last Name (NamePattern4) ] 1, Lipase 598. On arrival to the ICU, pt is intubated, sedated, has numerous eschar ulcers on right side of body and forehead, not responsive, appears comfortable. Review of systems: unable to obtain Past Medical History: "knee and hip replacement" [First Name8 (NamePattern2) ] [Hospital1 ] records: ATRIAL FIBRILLATION OTH SCREEN [Last Name (un) ]-MALIGN NEOPLASM OF BREAST OSTEOPOROSIS NOS HYPERTENSION NOS ACUTE DIASTOLIC HRT FAILURE RHEUMATOID ARTHRITIS MECHANICAL LOOSENING OF PROSTHETIC JOINT ABN REACT-ARTIF IMPLANT KNEE JOINT REPLACEMENT STATUS NO PROC/CONTRAINDICATION EXAM PRE-OPERATIVE NEC PAINFUL RESPIRATION PAIN IN THORACIC SPINE FRACTURE ONE RIB-CLOSED FRACTURE, CAUSE NOS FX LUMBAR VERTEBRA-CLOSE HIP JOINT REPLACEMENT STATUS ANEMIA NOS DIVERTICULOSIS COLON (W/O MENT OF HEMORRHAGE) CHEST PAIN NOS JOINT PAIN-PELVIS ARTHROPATHY NOS-UNSPEC JOINT PAIN-L/LEG JOINT PAIN-SHLDER BACKACHE NOS ARTHROPATHY NOS-FOREARM MALF INT ORTHPED DEV/GRF Social History: hoarder, as per EMS when finding patient Family History: unable to obtain Physical Exam: Admission Physical Exam: Vitals: HR 155 in A fib, BP 100/82 on CMV VT 450, RR 14, FiO2 50%, PEEP 5, Peak pressure 19 platueu presure 17,, RR 19, 98% on vent General: somnolent, intubated, disheveled appearing, eschar ulcers all over right side of body HEENT: Sclera anicteric, drr MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: anterior breath sounds without crackles 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: cool, mottled extremities, poor capillary refill DISCHARGE PHYSICAL EXAM: General: Alert and oriented x name, disheveled appearing, eschar ulcers all over right side of body HEENT: Sclera anicteric, drr MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: anterior breath sounds without crackles 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 Pertinent Results: Admission Labs: [2161-2-21] 06:41AM BLOOD WBC-13.7* RBC-4.08* Hgb-10.7* Hct-37.0 MCV-91 MCH-26.3* MCHC-29.0* RDW-17.4* Plt Ct-317 [2161-2-21] 02:35AM BLOOD WBC-16.7* RBC-4.61 Hgb-12.2 Hct-41.7 MCV-91 MCH-26.4* MCHC-29.2* RDW-17.3* Plt Ct-345 [2161-2-20] 10:15PM BLOOD WBC-17.4* RBC-5.15 Hgb-13.9 Hct-45.5 MCV-88 MCH-27.0 MCHC-30.6* RDW-17.3* Plt Ct-386 [2161-2-20] 10:15PM BLOOD Neuts-95.5* Lymphs-2.3* Monos-2.0 Eos-0 Baso-0.1 [2161-2-21] 02:35AM BLOOD PT-18.4* PTT-25.1 INR(PT)-1.7* [2161-2-20] 10:15PM BLOOD PT-18.2* PTT-22.6* INR(PT)-1.7* [2161-2-21] 08:11PM BLOOD Glucose-97 UreaN-116* Creat-2.1* Na-156* K-4.8 Cl-130* HCO3-15* AnGap-16 [2161-2-21] 12:24PM BLOOD Glucose-223* UreaN-132* Creat-2.3* Na-159* K-3.5 Cl-131* HCO3-14* AnGap-18 [2161-2-21] 06:41AM BLOOD Glucose-489* UreaN-169* Creat-2.6* Na-157* K-3.9 Cl-128* HCO3-12* AnGap-21* [2161-2-21] 02:35AM BLOOD Glucose-130* UreaN-212* Creat-3.0* Na-171* K-4.2 Cl-135* HCO3-17* AnGap-23* [2161-2-20] 10:15PM BLOOD Glucose-167* UreaN-255* Creat-4.0* Na-169* K-5.4* Cl-127* HCO3-19* AnGap-28* [2161-2-21] 06:41AM BLOOD ALT-24 AST-24 LD(LDH)-269* AlkPhos-54 TotBili-0.6 [2161-2-21] 02:35AM BLOOD Amylase-172* [2161-2-20] 10:15PM BLOOD ALT-34 AST-30 CK(CPK)-450* AlkPhos-78 TotBili-1.0 [2161-2-21] 02:35AM BLOOD Lipase-235* [2161-2-20] 10:15PM BLOOD Lipase-598* [2161-2-20] 10:15PM BLOOD cTropnT-0.03* [2161-2-21] 08:11PM BLOOD Calcium-8.0* Phos-3.9 Mg-2.3 [2161-2-20] 10:15PM BLOOD Albumin-3.1* Calcium-8.5 Phos-9.1* Mg-4.4* [2161-2-20] 10:15PM BLOOD Osmolal-436* [2161-2-21] 02:35AM BLOOD TSH-0.75 [2161-2-21] 08:11PM BLOOD Cortsol-45.6* [2161-2-20] 10:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2161-2-21] 08:38PM BLOOD Type-ART Temp-37.9 Rates-/21 PEEP-5 FiO2-50 pO2-139* pCO2-24* pH-7.43 calTCO2-16* Base XS--5 Intubat-INTUBATED [2161-2-21] 03:28PM BLOOD Type-ART Temp-37.4 Rates-/20 PEEP-10 FiO2-50 pO2-160* pCO2-23* pH-7.41 calTCO2-15* Base XS--7 Intubat-INTUBATED Vent-SPONTANEOU [2161-2-21] 03:26AM BLOOD Type-ART Rates-22/ Tidal V-452 PEEP-5 pO2-78* pCO2-32* pH-7.32* calTCO2-17* Base XS--8 Intubat-INTUBATED Vent-CONTROLLED [2161-2-21] 01:20AM BLOOD pO2-315* pCO2-33* pH-7.30* calTCO2-17* Base XS--8 [2161-2-21] 08:38PM BLOOD Lactate-2.1* [2161-2-21] 03:28PM BLOOD Lactate-2.3* [2161-2-21] 03:26AM BLOOD Lactate-2.6* [2161-2-20] 10:38PM BLOOD Lactate-3.5* [2161-2-21] 03:26AM BLOOD freeCa-0.98* PERTINENT INTERVAL LABS: [2161-2-23] 03:18AM BLOOD WBC-19.8* RBC-3.66* Hgb-9.7* Hct-32.1* MCV-88 MCH-26.5* MCHC-30.2* RDW-17.7* Plt Ct-220 [2161-3-5] 02:44AM BLOOD WBC-6.2 RBC-3.40* Hgb-9.1* Hct-28.7* MCV-85 MCH-26.9* MCHC-31.9 RDW-17.9* Plt Ct-146* [2161-3-3] 03:15AM BLOOD Glucose-144* UreaN-22* Creat-0.6 Na-147* K-3.7 Cl-113* HCO3-30 AnGap-8 [2161-2-21] 02:35AM BLOOD Glucose-130* UreaN-212* Creat-3.0* Na-171* K-4.2 Cl-135* HCO3-17* AnGap-23* [2161-2-21] 06:41AM BLOOD Glucose-489* UreaN-169* Creat-2.6* Na-157* K-3.9 Cl-128* HCO3-12* AnGap-21* [2161-2-21] 12:24PM BLOOD Glucose-223* UreaN-132* Creat-2.3* Na-159* K-3.5 Cl-131* HCO3-14* AnGap-18 [2161-2-21] 08:11PM BLOOD Glucose-97 UreaN-116* Creat-2.1* Na-156* K-4.8 Cl-130* HCO3-15* AnGap-16 [2161-2-22] 03:34AM BLOOD Glucose-141* UreaN-102* Creat-1.9* Na-160* K-4.4 Cl-132* HCO3-16* AnGap-16 [2161-2-22] 11:52AM BLOOD Glucose-235* UreaN-85* Creat-1.7* Na-155* K-3.8 Cl-128* HCO3-16* AnGap-15 [2161-2-22] 09:00PM BLOOD Glucose-187* UreaN-63* Creat-1.3* Na-155* K-3.4 Cl-128* HCO3-17* AnGap-13 [2161-2-23] 03:18AM BLOOD Glucose-178* UreaN-52* Creat-1.2* Na-155* K-3.3 Cl-127* HCO3-17* AnGap-14 [2161-2-23] 11:55AM BLOOD Glucose-168* UreaN-42* Creat-1.0 Na-148* K-3.3 Cl-121* HCO3-19* AnGap-11 [2161-3-2] 05:34PM BLOOD Glucose-259* UreaN-27* Creat-0.7 Na-147* K-3.9 Cl-112* HCO3-31 AnGap-8 [2161-3-4] 04:06AM BLOOD Glucose-100 UreaN-17 Creat-0.5 Na-142 K-3.7 Cl-109* HCO3-27 AnGap-10 [2161-2-27] 02:57AM BLOOD ALT-212* AST-246* LD(LDH)-657* CK(CPK)-125 AlkPhos-104 TotBili-1.0 [2161-2-20] 10:15PM BLOOD Lipase-598* [2161-2-21] 02:35AM BLOOD Lipase-235* [2161-3-3] 03:15AM BLOOD Lipase-22 [2161-2-20] 10:15PM BLOOD cTropnT-0.03* [2161-3-4] 02:45PM BLOOD Calcium-7.7* Phos-4.7# Mg-1.9 [2161-2-28] 03:46AM BLOOD VitB12-710 [2161-2-20] 10:15PM BLOOD Osmolal-436 [2161-2-21] 02:35AM BLOOD TSH-0.75 [2161-2-21] 08:11PM BLOOD Cortsol-45.6* [2161-2-24] 05:24AM BLOOD Vanco-9.4* [2161-2-20] 10:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2161-2-21] 03:28PM BLOOD Type-ART Temp-37.4 Rates-/20 PEEP-10 FiO2-50 pO2-160* pCO2-23* pH-7.41 calTCO2-15* Base XS--7 Intubat-INTUBATED Vent-SPONTANEOU [2161-2-23] 08:14AM BLOOD Type-ART Rates-/21 Tidal V-500 PEEP-5 FiO2-40 pO2-131* pCO2-21* pH-7.50* calTCO2-17* Base XS--4 Intubat-INTUBATED Vent-SPONTANEOU [2161-2-21] 03:26AM BLOOD Lactate-2.6* [2161-2-21] 03:28PM BLOOD Lactate-2.3* [2161-2-21] 08:38PM BLOOD Lactate-2.1* [2161-2-22] 03:50AM BLOOD Lactate-1.5 [2161-2-22] 09:08PM BLOOD Lactate-1.8 DISCHARGE LABS: [2161-3-6] 02:53AM BLOOD WBC-2.9# RBC-3.08 Hgb-8.4* Hct-26.0* MCV-85 MCH-27.2 MCHC-32.1 RDW-18.0* Plt Ct-128* [2161-3-6] 02:53AM BLOOD Neuts-61.2 Lymphs-26.1 Monos-4.6 Eos-7.3* Baso-0.7 [2161-3-6] 02:53AM BLOOD PT-13.5* INR(PT)-1.3* [2161-3-6] 02:53AM BLOOD Glucose-121* UreaN-17 Creat-0.5 Na-138 K-3.7 Cl-105 HCO3-28 AnGap-9 [2161-3-5] 02:44AM BLOOD ALT-52* AST-22 LD(LDH)-344* AlkPhos-98 TotBili-0.4 [2161-3-6] 02:53AM BLOOD Calcium-7.6* Phos-1.5* Mg-1.8 CXR ([2-20]): IMPRESSION: 1. No pneumonia. Linear atelectasis better seen on CT. 2. Endotracheal tube 3.9 cm above the carina. 3. Right internal jugular catheter ends in the right atrium and could be pulled back 5 cm to place it in the mid to distal SVC. CT Abd/Pelvis ([2-21]): IMPRESSION: 1. No pneumonia. 2. No acute process in the abdomen or pelvis. No evidence of traumatic injury. 3. Multiple vertebral compression fractures in the thoracolumbar spine of unknown chronicity. Sternal fracture, probably subacute-chronic given the callus formation. 4. Right internal jugular catheter ends in the right atrium. 5. 5mm right middle lobe nodule. If patient has no risk factors for malignancy, this can be followed up with dedicated chest CT in 12 months. If pt has risk factors for malignancy (e.g. smoking history), dedicated chest CT is recommended in [6-30] months. 6. Fatty 2.1 cm lesion in left pelvis, likely post surgical fat necrosis or possibly dermoid in the left adnexa. Suggest a follow up imaging study be obtained in 6 months to ensure stability - since visualization may be difficult with ultrasound given its location this could be performed with pelvic CT. ECG Study Date of [2161-2-20] 10:05:02 PM Atrial fibrillation with a rapid ventricular response. Non-specific ST-T wave changes. No previous tracing available for comparison Portable TTE (Complete) Done [2161-2-23] at 11:41:34 AM FINAL The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. HIP UNILAT MIN 2 VIEWS LEFT PORT Study Date of [2161-2-23] 2:10 PM There is severe osteopenia, limiting the evaluation of the bony cortex. No definite fracture is seen. The patient is status post left hemiarthroplasty of the hip. There is no evidence of hardware loosening or failure. Numerous surgical clips are seen within the lower left pelvis. IMPRESSION: No fracture. CXR ([2-25]): Bilateral pleural effusions, large on the left and moderate on the right as well as mild pulmonary edema have progressed. Cardiomegaly is severe and unchanged. Mitral annulus calcification may indicate mitral regurgitation. No pneumothorax. CXR ([2-27]): Patient has had a history of recurrent episodes of pulmonary edema; today it is worse. There has been interval increase in cardiomegaly and pulmonary edema. Bilateral pleural effusion is seen. Lung volumes are stably low. Right-sided PICC catheter is seen terminating in the low SVC. There is no pneumothorax. CXR ([3-3]): Again marked cardiomegaly is identified and rather advanced dens calcifications occupy the mitral ring area. The latter finding matches the previous torso CT identified cardiac changes which included marked enlargement of the left atrium. The pulmonary vasculature is somewhat congested, but not significantly more than it was on the preceding study. The same holds for the hazy density on the lung bases and particularly on the left side over the whole hemithorax compatible with pleural effusions layering the posterior pleural spaces as the patient is placed supine. No significant interval change can be identified. There is no pneumothorax. CXR ([3-5]) As compared to the previous radiograph, there is no relevant change. Moderate cardiomegaly, mild-to-moderate bilateral pleural effusions, and subsequent areas of atelectasis. No evidence of newly occurred focal parenchymal opacities. Unchanged course of the nasogastric tube. Brief Hospital Course: Brief Hospital Patient Summary =================== 77 F found down x several days in hoarding environment admitted for pressure ulcers, hypernatremia, acute renal failure, AMS, SIRS. Active Issues =================== #Hypovolemic versus septic shock secondary to dehydration/ skin ulcer infection with sodium 170 and BUN 255, ARF and Anion-Gap metabolic acidosis: Patient admitted on [2161-2-21] extremely dehydrated, started on IV fluid resuscitation. Patient intubated and norepinephrine pressors on for a day and phenylephrine on for a day. Initial goal to decrease Na slowly, 169->159 within 24 hrs. Patient was 10L up after aggressive initial resuscitation and subsequent diuresis following extubation. On initial calculation, patient had 3L free water deficit. CK only 400 so less likely rhabdo. Patient's urine output picked up with initial resuscitation and her sodium corrected quickly to the 150s. Following extubation patient did continue to have difficulty maintain PO intake and her sodium increased again following a low of 145. Patient did endorse thirst but was still unable to maintain her fluid intake. She was seen by speech and swallow who recommended pureed solids, thin liquids and pills crushed in apple sauce and nutrition who recommended tube feeds if unable to maintain PO intake. Unfortunately, the patient was unable to tolerate PO liquids or solids (pouching in her cheek), thus an NG tube was placed [3-3] for tube feedings. #Urinary tract infection (pseudomonas, no sensitivities): Patient has been febrile starting [3-4]. F/u sensitivities at [Hospital1 18] laboratory. Pt w/ indwelling Foley, changed on [3-6] after urine culture growth. No growth on blood cultures. On [3-5], re-initiated vanc/zosyn, and narrowed to zosyn only on [3-6]. Recommend 8 day course, to finish [3-13]. .# Malnutrition: Pt on tube feeds at 50cc/hr continuously. Tubefeeding: Replete with fiber Full strength; Starting rate: 30 ml/hr; Advance rate by 10 ml q4h Goal rate: 50 ml/hr. Residual Check: q4h Hold feeding for residual >= : 200 ml. Flush w/ 50 ml water q6h. Have been repleting electrolytes PRN in setting of malnutrition. # Acute encephalopathy, toxic metabolic: unclear origin although waxing and [Doctor Last Name 688] and likely delirium, w/out able to take POs, in ICU, elderly. Unclear baseline. Also possible is medications vs initial hypernatremia vs infection vs pain vs effects of intubation/ICU delirium. Now much more alert and awake but still with significant deficits. Recent TSH 0.75. B12 / RPR wnl. Pt currently being treated for UTI. Continues waxing and [Doctor Last Name 688] course. Keep up tube feeds. skin check qd. Continuing to enforce sleep cycles, keep up in chair, re-orient PRN. Decreased fentanyl patch from 50mg to 37mg. #Generalized pain: Most likely secondary to extremely severe skin wounds. no acute fracture per radiology. Patient has realized reasonable pain relief with liquid tylenol q6hrs PRN, dilaudid 0.25-0.5 q3hrs PRN, oxycodone 5-10mg q2hrs PRN breakthrough pain, fentanyl patch 37mg q72 hrs. Requires PRN dosages prior to procedures, wound dressing changes, bed movements. #Unstageable pressure ulcers contributing to sepsis/ hypotension above and causing pain: Pt with tachycardia, hypothermia, leukocytosis, initially with BP 70s, lactate 3.5, AMS, although no clear source of infection. Would consider ulcers, aspiration pneumonia (not appreciated on Chest CT and O2 sat has been fine prior to vent), UTI, sinusitis. Pancreatitis can also presents with several SIRS criteria. Skin cultures were remarkable for pseudomonas. Patient treated with Zosyn for 7 days (last day [2-28]) and Vancomycin for 6 days, renally dosed. While in the ICU, patient received tetanus vaccine. Pain control in the ICU was achieved with oxycodone (patient on Vicodin at home) and IV fentanyl. On [3-1] patient received 250 micrograms of fentanyl and was transitioned to a fentanyl patch 50 micrograms/hour. Currently, pt is patient has realized reasonable pain relief with liquid tylenol q6hrs PRN, dilaudid 0.25-0.5 q3hrs PRN, oxycodone 5-10mg q2hrs PRN breakthrough pain, fentanyl patch 37mg q72 hrs. Daily dressing changes, and guidance from wound nurses # A fib: Had been in RVR off and on throughout ICU stay. Was on dilt and metop at home, as well as warfarin. Patient unable to take POs now. Afib w/ RVR responsive to IV metoprolol. Have continued NG tube placement for PO medications. continue dilt 60mg qid PO and metoprolol to 25 mg PO tid. Patient currently subtherapeutic on warfarin, have restarted warfarin 1mg qd. #pancytopenia: potentially from methotrexate administration last week. Zosyn can cause but has been on before. Would recommend getting CBC daily until counts start to rise. #Transaminitis: Stable to resolving. Most likely reaction from previous methotrexate infusion vs. hypotension. Have continued to trend. No e/o RUQ tenderness. # RA: Chronic. Confirmed with Dr. [Last Name (STitle) ] [Telephone/Fax (1) 76066] PCP about home medication listing and fact that neck pain is not regular RA distribution. Would recommend not giving methotrexate as concern may have caused transaminitis and ? pancytopenia. continued 10mg prednisone daily Transitional Issues ==================== Radiology incidental findings - 5mm right middle lobe nodule. If patient has no risk factors for malignancy, this can be followed up with dedicated chest CT in 12 months. If pt has risk factors for malignancy (e.g. smoking history), dedicated chest CT is recommended in [6-30] months. - Fatty 2.1 cm lesion in left pelvis, likely post surgical fat necrosis or possibly dermoid in the left adnexa. Suggest a follow up imaging study be obtained in 6 months to ensure stability - since visualization may be difficult with ultrasound given its location this could be performed with pelvic CT. - trend LFTs - PT treatment - rheumatology eval s/p recovery - methotrexate being held in setting of elevated LFTs and ? pancytopenia -- would be wary of restarting - warfarin 1mg qd restarted - Dr. [Last Name (STitle) ] [Telephone/Fax (1) 76066] - clear RA development, question upper vertebra. This physician has had extensive relationship with patient (more so than most of her relatives). [Name2 (NI) ] Dr. [Last Name (STitle) ], patient would not want to be kept alive on a ventilator if not able to get off. She would not want to have CPR and would not want intubation unless reversable process, no defibrillation. - [Name (NI) ] (nephew) - [Telephone/Fax (1) 92014] - [Last Name (LF) ],[First Name3 (LF) ] Relationship: BROTHER Phone: [Telephone/Fax (1) 92015] - [Name2 (NI) ]rdianship needed (unable to promote an individual on her own to HCP): court had appointed a Ms. [First Name8 (NamePattern2) 11765] [Last Name (NamePattern1) 64386] as the guardian, which should become official on Tuesday. - Daily dressing changes - CBC daily until counts trend up - call [Hospital1 18] lab to f/u sensis on pseudomonas in urine Disposition: Ms. [Known lastname 92016] is being transferred to [Hospital 8629] in [Location (un) 1110]; the clinical nurse liaison is [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 92017]). SW spoke with her brother [Doctor Last Name 122] re the transfer and provided him with the contact information for the facility. Medications on Admission: Lasix 20mg daily dilt 240 daily warfarin 2.5 asdir metoprolol 25 [Hospital1 ] mtx 2.5mg tab 7 tab 1x weekly prednisone 10mg daily ([12-27]) percoset 5/325 po q6h prn vicadin 5/500 q6h prn ca/vit D 350-125 daily Discharge Medications: See Attached Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 1110] Discharge Diagnosis: Septic Shock from Pulmonary/Skin Source ALtered mental status, acute encephalopathy Hypernatremia Urinary Tract Infection Malnutrition Atrial Fibrillation Unstageable Pressure Ulcers Discharge Condition: serious Discharge Instructions: Ms. [Known lastname 92016], It has been a pleasure taking care of you. You are being transferred to [Hospital 8629] in [Location (un) 1110]; the clinical nurse liaison is [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 92017]). Social work spoke with your brother [Doctor Last Name 122] re the transfer and provided him with the contact information for the facility. Followup Instructions: You should follow-up with your primary care provider and any other pertinent specialists after you recover from the [Hospital 92018].	[ "276.0", "284.19", "427.31", "263.9", "787.22", "995.92", "428.33", "041.7", "584.9", "038.9", "348.39", "785.52", "714.0", "707.09", "780.96", "599.0", "518.81", "E849.8", "E933.1", "790.4", "428.0", "707.25" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04", "96.08", "38.91", "38.97" ]	icd9pcs	[ [ [] ] ]	21942, 22025	14128, 21635	314, 396	22252, 22261	4228, 4228	22736, 22876	3085, 3104		21905, 21919		22046, 22231		21661, 21882				22285, 22713					9430, 14105								3144, 3761																					2226, 2244					264, 276							424, 2207						4245, 9414											2266, 3010	3026, 3069						3786, 4209
74,794	169,213	39655	Discharge summary	report	Admission Date: [2138-7-11] Discharge Date: [2138-7-25] Date of Birth: [2070-6-23] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4679] Chief Complaint: shortness of breath and chest pain for two days Major Surgical or Invasive Procedure: Thoracentesis and chest tube placement video-assisted thorascopic surgery History of Present Illness: 68 year-old M with H/O A fibb on Coumadin, COPD, HTN, DM2, and extensive tobacco Hx who presented to an OSH with progressive SOB and pleuritic chest pain X 2 days and was found to have a large left-sided pleural effusion with compressive atelectasis. He received Zosyn 4.5mg IV x 1, 2 units of FFP and vitamin k for a supratherapuetic INR and was transferred to [Hospital1 18]. . In the ED his vitals were T 98.4 HR 120 BP 133/81 RR 24 O2 sat 94%. He had a leukocytosis of 34, left shift with 6 bands, and INR of 2.5. He received additional FFP & DDAVP and was transferred to the ICU. Interventional Pulmonology was consulted, performed a thoracentesis, placed a pigtail drain, which drained 1.2 L of turbid yellow fluid (procedure stopped [1-21] worsening SOB and pain). The patient's respiratory status worsened (ABG 7.28/50/96), required NRB, weaned to 60% facemask. It was thought this could be secondary to re-expansion of a diseased lung or pulmonary edema. He was started on Vanco and Zosyn. His UOP dropped and he became HOTN, which resolved with fluids. Vanc was discontinued. Patient improved and was transferred to the floor, requiring 4L O2 on NC. . Currently, he reports continued shortness of breath and pain with deep inspiration. He has had an intentional 25 lbs weight loss over the last 2 months. He has had SOB for over a year, which he attributed to his smoking history. It is worse on exertion, would be huffing after one flight of stairs, denies orthopnyea, PND, or leg swelling. He is followed by a cardiologist and has had 2 stress tests in the past, results unknown per patient. . He also has chronic back and B/L knee pain. He denies F/C/sweats, sick contacts, cough, sore throat, abdominal pain, N/V/D/C, no dysuria, frequency, no HA, numbness or tingling, seizures, no rash, no lumps or bumps, + easy brusising [1-21] coumadin. Past Medical History: COPD Afib on coumadin - new in the past 3 months HTN HLD DM-II Social History: Tobacco: 50 pack years, quit 1 year ago. Smoked 1ppd x 50 years. Alcohol: quit 34 years ago. Prior heavy alcohol use with scotch and whiskey. Lives with wife. [Name (NI) ] has 1 daughter and a grandaughter. Retired line foreman for an electric company now works as a parking attendent for a boat company to [Hospital3 4298]. Denies exposure to asbestos. Denies exposure to tubercluosis, prisons, homeless shelters, or exotic travel. Family History: Son died due to WPW (his wife also had this). Denies other cardiac or pulmonary diseases. Denies family history of rheumatoid arthritis or lupus. Physical Exam: VS: T: 98.2 HR: 89 AFib BP: 103/62 Sats: 95% RA at rest 90 w/activity Wt: BS 141 General: 68 year-old male in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: irregular Resp: decrease breath sounds LLL otherwise clear GI: obese, benign Extr: warm 3+ edema Incision: left thoracotomy site clean, dry, intact, margins well approximated Neuro: AA&O MAE Pertinent Results: [2138-7-22] WBC-15.4* RBC-3.35* Hgb-9.9* Hct-30.3 Plt Ct-389 [2138-7-21] WBC-18.8* RBC-3.09* Hgb-9.0* Hct-28.2 Plt Ct-366 [2138-7-18] WBC-30.6* RBC-3.65* Hgb-10.9* Hct-33.0 Plt Ct-519 [2138-7-11] WBC-34.2* RBC-3.81* Hgb-11.5* Hct-34.1 Plt Ct-491 [2138-7-25] INR(PT)-1.6* [2138-7-24] INR(PT)-1.4* [2138-7-23] INR(PT)-1.4* [2138-7-21] INR(PT)-1.2* [2138-7-20] INR(PT)-1.3* [2138-7-25] UreaN-21* Creat-1.2 Na-137 K-3.9 Cl-96 [2138-7-24] Glucose-178* UreaN-22* Creat-1.1 Na-137 K-4.0 Cl-97 HCO3-33 [2138-7-21] Glucose-177* UreaN-19 Creat-0.9 Na-135 K-3.9 Cl-98 HCO3-33 [2138-7-13] Glucose-244* UreaN-59* Creat-2.3* Na-133 K-4.0 Cl-101 HCO3-20 [2138-7-24] Calcium-8.1* Phos-3.6 Mg-2.0 Micro: [2138-7-18] Pleural and tissue cultures from OR No growth [2138-7-12] Blood cultures x 2 no growth [2138-7-12] Urine no growth CXR: [2138-7-24]: Interval removal of left chest tubes. Persistence of left hemidiaphragm elevation along with moderate left pleural effusion and left lower lobe atelectasis [2138-7-21]: the left chest tubes apparently have been placed on waterseal. No evidence of pneumothorax. The degree of opacification at the left base appears to have decreased somewhat. [2138-7-16]: Left-sided pleural effusion and left lower lobe consolidation remain unchanged. Opacities throughout the right lung seen on CT scan are below the resolution of the plain film. Otherwise, the cardiomediastinal silhouette, the hilar silhouette, and pleural surfaces remain unchanged. There is no pneumothorax. CCT: [2138-7-12]: 1. Partial drainage of multiloculated left effusion, with incomplete lung re-expansion and hydropneumothorax. Cannot exclude some superimposed consolidation in partially aerated left lower lobe. 2. New patchy ground glass opacities in right upper and middle lobes could reflect infectious or inflammatory process, or subpleural atelectatic change. 3. Severe calcific atherosclerosis and trace pericardial effusion. Renal Ultrasound: [2138-7-12] The right kidney is 10.8 cm in length. The left kidney is 10.9 cm in length. Cortical widths arem aintained. Echotexturesare within normal limits. No hydronephrosis, renal stone, or mass lesion identified. A Foley catheter balloon is identified in an incompletely distended bladder. IMPRESSION: Normal echotexture and size of bilateral kidneys with no hydronephrosis or stone identified. Foley in bladder. Brief Hospital Course: Mr. [Known lastname 87427] is a 68yo M w/hx of afib on Coumadin, DM2, COPD who presents with respiratory distress found to have a large left sided pleural effusion. . #PLEURAL EFFUSION: His elevated INR was reversed with FFP, vitamin K, ddAVP and he underwent diagnostic and therapeutic thoracentesis with pigtail placement by interventional pulmonology. Initial pleural fluid studies (pH 6.5, low glucose) suggested a complicated infectious process versus malignancy. Repeat imaging after effusion drainage did not show an obvious mass. He was started on broad spectrum antibiotics and then transition to Levaquin and completed a 2 week course. All of the cultures to date have no growth. Thoracic Surgery was consulted and he underwent Left thoracoscopy converted to left thoracotomy, decortication of lung on [2138-7-18]. He was transferred to the SICU intubated and on pressors. He weaned off the pressors, successfully extubated on [2138-7-22]. He transfer to the floor in stable condition. Chest tubes anterior, posterior and basilar were to water-seal. The posterior was remove on [2138-7-22]. The anterior on [2138-7-23] and the basilar on [2138-7-24] once the pleural cultures were negative. Chest films: serial chest films were done which showed pleural thickening on the left, elevation of the left hemidiaphragm and the appearance of the left basal and right lower lobe atelectasis. Respiratory; with aggressive pulmonary toilet, neb, chest PT, diuresis and ambulation he titrated off oxygen with saturations of 93%. . #ACUTE ON CHRONIC RENAL FAILURE: His creatinine was 3.5 on admission with clinical history, exam, and labs (FeNa 0.3) suggestive of pre-renal etiology. Renal ultrasound did not demonstrate obstruction or hydronephrosis to suggest post--renal etiology. Medications were renal dosed and nephrotoxic agents were held. He was given intravenous fluids and his creatinine improved. On [2138-7-22] he was volume overload and given IV Lasix with good response. He continue on Lasix while hospitalized and discharged on 40 mg PO. He had 3+ lower extremity. ACE wraps were applied. His cardiologist was notified and he will follow his volume status as an outpatient. . #ATRIAL FIBRILLATION: He was continued on diltiazem for rate control 70-80's. Digoxin was held in the setting of acute renal failure, then restarted upon resolution. His Coumadin was held and anticoagulation initially reversed in order for the pigtail catheter to be placed. Thereafter he was started on a heparin drip, which was discontinued prior to VATS. Anticoagulation (warfarin) was restarted on [2138-7-21] his home dose of 5 mg. On [2138-7-24] he was given 7.5 mg Coumadin for INR 1.4. and [2138-7-25] for INR 1.6. He will continue on his home dose of 5 mg and follow-up with his cardiologist on Monday. . #HTN: Initially his home antihypertensives were held. HCTZ was re-started for BP control. His blood pressure 89-110 and would not tolerate ACE at this time. . #DM2: His oral hyperglycemic medications were held. He was started on an insulin sliding scale. On [2138-7-23] his PO hyperglycemic meds were restarted. His blood sugars range were 150-170. . #DEPRESSION: He was continued on Wellbutrin. . #COPD: He was continued on symbicort and spiriva. Disposition: He was followed by physical therapy. His ambulation improved. He was discharged to home with his family and VNA. He will follow-up with his cardiologist on Monday for warfarin management and volume status. He will follow-up with Dr. [First Name (STitle) ] in 2 weeks for Chest CT with contrast. Medications on Admission: Wellbutrin SR 150 mg Tab Oral [Hospital1 ] Hydrochlorothiazide 25 mg Tab Oral PO daily Actoplus MET 15 mg-850 mg Tab Oral PO qHS Lipitor 40 mg Tab Oral PO daily Diovan 80 mg Tab Oral PO daily Hydralazine 25 mg Tab Oral PO BID Warfarin 5 mg Tab Oral Digoxin 125 mcg Tab Oral PO daily Cardizem LA 420 mg 24 hr Tab Oral PO daily Symbicort 80 mcg-4.5 mcg/Actuation Inhalation [Hospital1 ] Spiriva with HandiHaler 18 mcg INH [Hospital1 ] Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 4. Valsartan 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:30 Tablet(s) Refills:0 8. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 10. Diltiazem HCl 420 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 11. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Metformin 850 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 14. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:60 Capsule(s) Refills:2 16. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day: take with lasix. Disp:30 Capsule, Sustained Release(s) Refills:2 17. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:70 Tablet(s) Refills:0 18. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: VNA Assoc. of [Hospital3 ] Discharge Diagnosis: Pneumonia with left pleural effusion COPD Atrial fibrillation on coumadin Hypertension DM-II Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr, [Name (NI) ] office [Telephone/Fax (1) 2348] if you experience: -Fever > 101 or chills -Increased shortness of breath, cough or chest pain -Incision develops drainage -Chest tube site cover sites with a bandaid until healed -You may shower. No tub bathing or swimming until incision healed -Continue fingerstick blood sugars. -Daily weights. Call you cardiologist if you have [2-20] pound weight gain. -ACE WRAPS both lower extemities during the day. OFF at night Keep legs ambulated while sitting. -Take Warfarin 7.5 mg [2138-7-25] then 5 mg Sat & Sun. Follow-up with Dr. [Last Name (STitle) 87428] on Monday Followup Instructions: Follow-up with Dr. [First Name (STitle) ] [0-0-] [2138-8-5] 4:00pm on the [Hospital Ward Name 5074] [Hospital Ward Name 23] Clincal Center [Location (un) 24] CAT SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2138-8-5] 10:15 [Location (un) 861] Radiology [Hospital Ward Name 23] Clinical Center. NOTHING TO EAT OR DRINK 3 hours before TEST Coumadin follow-up with your Cardiologist Dr. [Last Name (STitle) 19944] [Telephone/Fax (1) 19666] on Monday. Follow-up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] [Telephone/Fax (1) 36175] within the next 2 weeks Completed by:[2138-7-25]	[ "V15.82", "427.31", "518.0", "V64.42", "585.9", "403.90", "276.2", "276.6", "486", "V58.61", "288.60", "311", "250.00", "511.9", "496", "285.9", "584.9" ]	icd9cm	[ [ [] ] ]	[ "34.51", "33.22", "96.71", "33.24", "34.04", "34.91" ]	icd9pcs	[ [ [] ] ]	11944, 12005	5982, 9616	369, 444	12142, 12142	3499, 5959	12960, 13628	2906, 3056		10111, 11921		12026, 12121		9642, 10088				12293, 12937													3071, 3480																										282, 331							472, 2342											12157, 12269						2364, 2429	2445, 2890
14,849	122,681	47770	Discharge summary	report	Admission Date: [2197-8-15] Discharge Date: [2197-8-24] Date of Birth: [2148-6-8] Sex: F Service: ORTHOPEDIC HISTORY OF PRESENT ILLNESS: The patient is a 47 year-old genetics professor who has a prior right thoracic scoliosis fusion with mild disc degenerative of the lumbar spine of L3 and L4. She has no other medical problems except for reflux. PAST MEDICAL HISTORY: Her past medical history is largely benign. MEDICATIONS: Nasocort. HOSPITAL COURSE: She underwent an anterior spinal fusion T11-L3 with T11-12 and T12 one osteotomies on the 25th of period well and was initially did well following that procedure. The patient subsequently was managed in the Surgical Intensive Care Unit for close monitoring. The patient subsequently went back to the Operating Room on the 28th for a posterior fusion of T2 to L3 with iliac crest bone graft. Following this she was managed in the Surgical Intensive Care Unit. The patient was stable in the Surgical Intensive Care Unit. She had some change in mental status related to her narcotic medications initially postoperatively. These changes subsequently resolved as her medications were adjusted. She was fitted for a TLSO. She was kept on perioperative antibiotics and was kept on postoperative pneumoboots and TEDS for deep venous thrombosis prophylaxis. She was subsequently transferred to the floor on [8-21]. Her floor hospital course was subsequently unremarkable. She did well with physical therapy and occupational therapy and was deemed a good rehab candidate. Her pain was well controlled on oral pain control and she mobilized well with physical therapy. At discharge her incisions are clean, dry and intact. Her neurological is stable and intact in bilateral lower extremities for sensory and motor. She will be out of bed with a TLSO. She will follow up with Dr. [Last Name (STitle) 363] in two weeks. DISCHARGE MEDICATIONS: Prilosec 20 mg po q day. Paxil 30 mg q.d. Oxycontin 30 mg q.a.m. and 20 mg q.p.m., Vicodin one to two po q day. Ativan 1 mg po t.i.d. prn. Albuterol, Atrovent nebs as needed. She should be on a regular diet, occupational training and physical therapy gait training. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 3863] Dictated By:[Doctor First Name 100844] MEDQUIST36 D: [2197-8-24] 07:40 T: [2197-8-24] 07:49 JOB#: [Job Number ]	[ "285.9", "493.90", "737.30", "722.10" ]	icd9cm	[ [ [] ] ]	[ "77.79", "81.04", "81.05" ]	icd9pcs	[ [ [] ] ]									1949, 2488					493, 1925																																																	170, 382																	405, 475
75,993	121,276	36832	Discharge summary	report	Admission Date: [2155-9-4] Discharge Date: [2155-9-10] Date of Birth: [2101-2-26] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1943] Chief Complaint: Low back pain. Major Surgical or Invasive Procedure: Bronchoscopy with tissue biopsy on [2155-9-5]. History of Present Illness: 54-year-old portugese-speaking Brazilian woman (limited english, translation via daughter) with metastatic bronchogenic carcinoma, bilateral pulmonary emboli, history of back surgery, disk herniation, who is transferred from [Hospital 8] hospital [2155-9-4] for evaluation for cord compression. She presented to [Hospital ] hospital on [2155-9-3] with worsening mid to upper back pain and inability to walk. She awoke at 3:30 AM prior to admission with upper back pain that prevented her from standing. She had no numbness, bowl or bladder sx, tingling, weakness, or shooting pain. She presented to [Hospital1 3494] ED, with an intial sat of 84% on RA. She had CT torso showing bilateral pulmonary emboli and right-hilar and lower-lobe infiltrate mass, consistent with bronchogenic carcinoma with mets to back and liver. She was admitted to the ICU. She had back pain that was concerning and weakness that was concerning for cord compression vs. limitation from pain. She was started on dexamethasone 10 mg once followed by 4 mg q6H. She had spine MRI that showed multiple small foci of enhancement in the brain and spine mets with cord edema. She had Q1H neuro exams with no focal deficits. She remained hemodynamically stable w/r/t her PE with a sat of 100% on RA and no right heart strain on EKG. On transfer she had an IVC filter placed (not anticoagulated due to brain mets, concern for bleeding). She has been stable and had pathology sent from endobronchial biopsy, awaiting final result. Currently she notes minimal ([2156-1-31]) back pain located on the left in the mid-thoracic region without radiation or pleuritic component. She is tolerating the TLSO brace well, without dyspnea. She acknowledges non-productive cough. ROS: 6 lbs wt loss in 10 days prior to presentation, no fevers, chills, night sweats. She has not had a BM in 3 days which is unusual for her and feels constipated. She notes nausea with pain medications. 10 point review of systems negative except as noted above. Past Medical History: Herniated Disk Back surgery in [Country 4194] Left clavicular fracture repair Left eye glaucoma, remote history Herpes opthhalmicus on acyclovir Oncology History: Found to have a pulmonary nodule in [3-9] in [Country 4194], with no follow up. She was then seen at [Hospital1 3793] in [2155-7-22] for left clavicular pain after hitting a table and breaking her clavicle. She had studies showing a lung nodule and was referred to heme-onc for work-up. She decided to go to [Country 4194] instead because she didn't have health insurance, but was told there that everything was normal and given pain medications. She then presented to [Hospital 8] hospital on [2155-9-3], described above. Social History: Lives in [Location 4194] with husband, comes to visit daughter in [Name (NI) 3494]. Works in the cleaning industry with significant detergent and fume exposure. Non-smoker. Denies Alcohol or drug use. Family History: Mother died from brain cancer. Physical Exam: VS: T 99.2 HR 90 BP 108/77 RR 18 Sat 96% 2L NC Gen: Thin, well appearing woman in NAD Eye: extra-ocular movements intact, pupil 3mm->2mm OD, 8mm irregular, non-reactive OS, sclera anicteric, not injected, no exudates ENT: mucus membranes moist, no ulcerations or exudates Neck: no thyromegally, JVD: Cardiovascular: regular rate and rhythm, normal s1, s2, no murmurs, rubs or gallops Respiratory: Clear to auscultation bilaterally, superiorly/anteriorly Abd: Soft, non tender, non distended, bowel sounds present, guaiac negative Extremities: No cyanosis, clubbing, edema, joint swelling Neurological: Alert and oriented x3, CN III-XII intact, normal attention, sensation normal, asterixis absent, speech fluent, DTR's 1+ patellar, achilles, biceps, triceps, brachioradialis bilaterally, babinski down-going bilaterally, strength 5/5 upper extremities and lower extremities throughout Integument: Warm, moist, no rash or ulceration Psychiatric: appropriate Pertinent Results: CXR [2155-9-4]: Right-sided hilar mass in patient with history of carcinoma. No pneumothorax or pleural effusion. Referral is made to newly entered chest CT performed at other hospital. CT T- and L-Spine [2155-9-4]: 1. Complete collapse of vertebral body of T6, likely pathologic fracture, with metastatic involvement of the right pedicle at this level. Metastatic involvement of vertebral body of L1, lower left portion, with involvement of the left pedicle. 2. Lucent lesion in the right iliac bone, with cortical destruction and extension in the soft tissue. 3. Right hilar mass, with associated atelectasis, in keeping with diagnosis of known lung cancer. Atelectasis at the left lung. Prominent lymph nodes in the mediastinum and hilum. 4. Prominence of the adrenal glands bilaterally, likely metastatic involvement. 5. Lesion in the liver, likely metastatic deposit. Final Attending Comment: In addition to above there is likely epidural tumor at T6 indenting the cord which would be better assessed by MRI.There is epidural soft tissue at L1 also which could represent prominent vein versus epidural tumor. Pathology Examination [2155-9-5]: SPECIMEN SUBMITTED: ENDOBRONCHIAL BX (1 JAR) DIAGNOSIS: Lung, right lower lobe, endobronchial biopsy: Poorly-differentiated squamous cell carcinoma. CT Torso [2155-9-8]: IMPRESSION: 1. Extensive mediastinal and right hilar lymphadenopathy with right lower lobe lung mass as described above. There is encasement of the right lower lobe superior segment, causing worsening atelectasis of the right lower lobe. 2. Metastatic deposit within the liver, left adrenal gland and osseous structures as described above. 3. Small pulmonary embolus in right middle lobe pulmonary artery and thrombus in situ in IVC filter. 4. Pathologic compression fracture of T6. 5. Metastatic disease to bones: left clavicle pathological fracture associated with a lytic lesion (3:7), several ribs, iliac [Doctor First Name 362], left femoral head, right humeral head Brief Hospital Course: 1. Squamous cell carcinoma of lung metastatic to brain/spine/bones/liver/adrenals: Diagnosis made from tissue obtained by bronchoscopy on [9-5]. Pathology results showed poorly differentiated squamous cell carcinoma. Hematology Oncology was consulted and recommended the patient get started with palliative radiation first and patient can follow up with thoracic oncology as an outpatient. Orthopedic oncology was consulted for left femoral head tumor and they did not recommend any surgical intervention at this time given that patient was ambulatory and pain free in her leg. Rather they will follow up with the patient as an outpatient. 2. Vertebral compression fracture, metastatic: Neurosurgery consult stated that no intervention recommended at this time. She was placed in a TLSO brace when upright or out of bed per neurosurgery recommendations. XRT was started on [2155-9-9] with no improvement of her symptoms. Pt given fentanyl patch for pain control and prn narcotics along with a robust bowel regimen. 3. Pulmonary emboli: The patient was found to have bilateral pulmonary emboli on CT performed at the outside hospital. She was hemodynamically stable. Given brain met/spine mets, she was not started on on anticoagulation. A removable IVC filter was placed. 4. Herpes ophthamicus: The patient is followed by [Hospital 39111] for this condition. She is currently in the midst of a 2 year course of acyclovir; this was continued. She will follow up as an outpatient. 5. Long-term plan: The patient is very interested to return to [Country 4194] where most of her family lives as soon as possible and before she is unable to travel. She and her family understand the poor prognosis of her disease. Medications on Admission: Acyclovir 800 mg PO daily Percocet Ultram 37.5mg/paracetamol 325 mg PO daily of note has been receiving dilaudid 0.5mg iv q3-4 hours with relief Discharge Medications: 1. Acyclovir 800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:60 Capsule(s) Refills:0 3. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY (Daily). Disp:30 Refills:0 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:30 Adhesive Patch, Medicated(s) Refills:0 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO every twelve (12) hours as needed for constipation. Disp:100 Tablet(s) Refills:0 6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for pain. Disp:100 Tablet(s) Refills:0 7. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain: Use for moderate or severe pain as needed. Disp:50 Tablet(s) Refills:0 8. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours. Disp:10 patches Refills:0 9. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours. Disp:10 patches Refills:0 10. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. Disp:28 Tablet(s) Refills:0 11. Zofran 4 mg Tablet Sig: One (1) Tablet PO twice a day as needed for nausea. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: 1. Metastatic squamous cell cancer of the lung 2. Compression fracture of the 6th thoracic vertebra 3. Pulmonary embolus 4. Herpes ophthalmicus Discharge Condition: Fair condition. Discharge Instructions: You have a fracture in your spine that was evaluated by neurosurgery and they determined it to be stable currently. You should wear a special brace. Please wear this brace whenever you are sitting or standing. If you go on a long trip (car or airplane), please get up and walk around every one or two hours to reduce the risk of developing blood clots. Seek medical attention if you develop worsening of symptoms including pain, shortness of breath, weakness, or other concern. Followup Instructions: 1. Continue your treatments with Radiation Oncology 2. You will be called for an appointment with Thoracic Oncology 3. You will be called for an appointment with Orthopedic Oncology	[ "198.7", "162.5", "054.40", "733.13", "197.7", "415.19", "054.9", "198.5", "198.3" ]	icd9cm	[ [ [] ] ]	[ "33.27", "38.7" ]	icd9pcs	[ [ [] ] ]	9831, 9837	6481, 8218	329, 381	10025, 10043	4443, 6458	10572, 10757	3419, 3451		8414, 9808		9858, 10004		8244, 8391				10067, 10549													3466, 4424																										275, 291							409, 2435																	2457, 3177	3193, 3403
29,256	199,912	2598	Discharge summary	report	Admission Date: [2198-9-19] Discharge Date: [2198-9-20] Service: MEDICINE Allergies: Codeine / Nsaids / Dicloxacillin / Metronidazole / Vancomycin Attending:[First Name3 (LF) 2297] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ] yo female s/p recent R Occipal Lobe infarction, AAA, CAD, PVD, HTN presents to the [Hospital1 18] ED after she was unable to communicate with her son over the phone. At home, her son found her to be lethargic and called EMS. She was initially presented as being "unable to walk," but upon arriving to the ED, she was able to move her LEs and she was found to be AAO x 3 despite having a blood pressure of 46/36. - At this time: HR: 80s RR: 20 92% on 4L NC - Started on peripheral dopamine - 3 peripheral IVs were placed when cordis attempt failed - She was also started on peripheral neo for better BP control; this was eventually weaned off prior to coming to the ICU. - 3.5L IVFs - Vancomycin/Ceftriaxone - Per the family, this declined any surgical interventions or any further attempts at a CVL. Past Medical History: Peripheral Vascular Disease- s/p L SFA, L iliac stent, R fem-[Doctor Last Name ] bypass [2181] Hypertension CAD s/p MI CHF Dementia CRI AAA Social History: Retired banker. Lives alone with VNA. Ambulates occasionally with cane, usually without. No tob/etoh. Family History: History of Peripheral vascular disease. No history of stroke. Son with detached retina. Physical Exam: T-96.5 BP-94/52 HR-100 A Fib RR- O2Sat 96% 4LNC Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit CV: Irregular S1 and S2, LSB ejection murmur Lung: crackles at bases L>R aBd: +BS soft, nontender ext: no edema Pertinent Results: TTE: The left atrium is elongated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is severely depressed (LVEF= 25-30 %) with global hypokinesis, inferior, septal and apical akinesis. There is no ventricular septal defect. Right ventricular chamber size is normal. Right ventricular systolic function is borderline normal. The ascending aorta is moderately dilated. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The tricuspid valve leaflets are mildly thickened. The tricuspid regurgitation jet is eccentric and may be underestimated. There is borderline pulmonary artery systolic hypertension. There is a small to moderate sized pericardial effusion. There are no echocardiographic signs of tamponade. . [2198-9-19] 02:20PM CK-MB-37* MB INDX-10.5* cTropnT-1.26* [2198-9-19] 02:20PM CK(CPK)-351* [2198-9-19] 05:00AM CK-MB-19* MB INDX-8.1* cTropnT-0.32* proBNP-[Numeric Identifier 13106]* [2198-9-18] 10:29PM CK-MB-NotDone cTropnT-0.05* Brief Hospital Course: 1. Shock: likely from acute MI, possible underlying PE given RV strain pattern on ECG. Echo without evidence of tamponade. She required dopamine to maintain adequate blood pressure. Ultimately, the peripheral IV through which the dopamine was infusing infiltrated and the patient did not want an additional IV placed. She asked for comfort measures only and ultimately succumed to her disease. The last set of cardiac enzymes were elevated, cause of death is acute myocardial infarction. . 2. Acute renal failure: from hypotension. renal ultrasound unrevealing. . 3. Hypoxia: from acute MI and likely PE . 4. AAA: not candidate for surgery. Increased in size since recent scan. No evidence of extension into renal arteries. . 5. Pericardial effusion: incidental finding. Echo without evidence of tamponade. . 6. Anion gap metabolic acidosis: from ARF. . 7. Disposition: DNR/DNI. The patient was made CMO by her wishes and those of her son. She passed away with family at bedside. Medications on Admission: 1. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr Sig: One (1) Cap PO BID (2 times a day). 2. Atorvastatin 40 mg PO DAILY 3. Aspirin 325 mg PO DAILY 4. Protonix 20 mg Tablet once a day. 5. Atenolol 12.5 mg 6. Lisinopril-Hydrochlorothiazide 10-12.5 mg Tablet PO once a day. Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: 1. Acute myocardial infarction 2. Abdominal aortic aneursym 3. Acute renal failure 4. Anion gap metabolic acidosis 5. Peripheral vascular disease 6. s/p Cerebrovascular accident 7. Hypertension 8. Coronary artery disease 9. Dementia 10. Non-insulin dependent diabetes mellitus 11. Gastroesophageal reflux disease 12. Asbestos-related lung disease Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired	[ "428.0", "585.9", "276.51", "414.01", "410.71", "584.9", "530.81", "250.00", "403.90", "438.9", "276.2" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	4856, 4865	3503, 4488	281, 287	5255, 5264	1881, 3480	5320, 5330	1454, 1543		4827, 4833		4886, 5234		4514, 4804				5288, 5297													1558, 1862																										230, 243							315, 1143																	1165, 1315	1331, 1438
41,897	169,630	45126	Discharge summary	report	Admission Date: [2144-3-30] Discharge Date: [2144-4-24] Date of Birth: [2071-9-8] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 602] Chief Complaint: HYPOXIA Major Surgical or Invasive Procedure: Fistulogram and fistula thrombectomy Electrophysiology study following PEA arrest Pacemaker implantation following PEA arrest History of Present Illness: 72M with bipolar disorder, CAD s/p CABG and HD-dependent ESRD from lithium toxicity and interstitial nephritis, now admitted from outpatient transplant surgery clinic (where he had been sent by his [Hospital1 1501] for planned AVF thrombectomy) with hypoxemia. . Pt discharged from [Hospital1 18] in [2143-2-19], had been living at a [Hospital1 1501] and attending outpatient dialysis centers in the interim. Trouble with dialysis access on [2144-3-28] prompted a planned thrombectomy of clotted AV graft. While there, he was found to be hypoxic to the 70s on RA, SOB and w/ N/V. Emesis was non-bilious, non-bloody. No chest pain, abdominal pain or diarrhea. No fever. Some increased LE edema. He missed dialysis on Saturday because he was in the [Last Name (LF) ], [First Name3 (LF) ] he was last dialyzed Thursday [3-26] (4 days prior to admission). . In the ED, initial VS 98.0 51 116/55 22 100% 6L NC. Labs notable for K 6.8, Cr 9.8/BUN 99, and anion gap of 20. CXR showed RUL/RML pneumonia and LLL pleural effusion with scarring vs pneumonia. He received 160 mg lasix IV x1 and 2g calcium gluconate for his hyperkelemia plus vancomycin 1g and levofloxacin 500 mg. VS upon transfer 97.8 hr 76 rr 14 b/p 122/65 96% 2 liters. . On arrival to the floor he was comfortable and had no complaints. He says he feels completely well and like his usual self, and he is quite surprised to hear he has pneumonia. . Renal consult team, who saw him in the ED and shortly after arrival to the floor, decided that he needed to have a temporary dialysis cath placed for emergent dialysis. He was quickly transported off the floor for placement of the catheter, and while in the dialysis was found to go into asystole. A code blue was called. On review of his telemetry stips, he had a period of sinus bradycardia before going into one or two brief episodes of asystole. . He quickly regained a pulse following 30-60 seconds of chest compressions. After the asystolic event he was briefly bradycardic in the 20s with what appeared to be a ventricular escape rhythm. He was given atropine and 1g calcium gluconate, given his hyperkalemia on admission. His rate improved to the 80-90s. A stat chem panel showed K of 5.6, pH of 7.26, pCO2 of 41 and p02 of 213. Repeat CXR showed no major changes compared to admission CXR (notably no PTX). He was then urgently transferred to the MICU for further management. Past Medical History: Past Psychiatric History: - MDD vs BPAD type 1 - previous trials of lithium (was helpful but caused kidney toxicity), depakote (was discontinued) - several ([4-23]) hospitalizations in lifetime - No prior suicide attempts - outpt therapist [First Name5 (NamePattern1) 1158] [Last Name (NamePattern1) 96334] [Telephone/Fax (1) 96336] - PCP prescribes psychiatric medications Past Medical History: -ESRD [2-20] lithium exposure and chronic interstitial nephritis on HD (Tue/[Doctor First Name ]/Sat) -DI from Lithium toxicity -Normal pressure hydrocephalus s/p drain at [Hospital1 112] in [2138] (no shunt seen on imaging) -Hypertension -Anemia of chronic disease -H/o endocarditis -Pulmonary lymphadenopathy Past Surgical History: -CABG x 4, resection of tumor from left ventricular outflow tract [2141-1-27] -Left brachiocephalic AV fistula placed [2139-9-23] -Left forearm radiocephalic AV fistula [2139-5-12] -Appendectomy -Tonsillectomy Social History: - formerly worked at the MFA as a security guard - never married, no children - lives alone in [Location (un) 2030] [Location 96345]graduate Family History: History of depression in his father. Physical Exam: ADMISSION EXAM VS - 99.2, 82, 118/58, 24, 98%2L GENERAL - NAD, comfortable, appropriate, conversant HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, 2.6 systolic murmur left sternal border ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3 . DISCHARGE EXAM VS T 98.9 BP 128/75 HR 74 RR 18 O2 100/RA GEN thin, disheveled unshaven man sitting up in chair HEENT: NCAT MMM OP clear, partially edentulous CHEST: CTAB, no r/r/w. R chest pacemaker site dressing c/d/i, no hematoma/ecchymosis/tendernes CV: RRR S1 S2 nl, soft systolic murmur ABD: soft, non-tender, BS normoactive. No TTP. EXT: L arm HD fistula site CDI, + bruit/thrill, legs wwp, no edema. PSYCH: AOX3, pressured speech, hypersexual thoughts frequently articulated, alternatingly agitated/argumentative and silent/pensive-appearing, mood "good" affect manic Pertinent Results: ADMISSION LABS [2144-3-30] 10:00AM BLOOD WBC-8.3 RBC-3.21* Hgb-11.0* Hct-32.2* MCV-100* MCH-34.1* MCHC-34.0 RDW-15.5 Plt Ct-182 [2144-3-30] 10:00AM BLOOD PT-12.7* PTT-24.6* INR(PT)-1.2* [2144-3-30] 10:00AM BLOOD Glucose-63* UreaN-99* Creat-9.8# Na-139 K-6.8 Cl-97 HCO3-22 AnGap-27* [2144-3-31] 02:56PM BLOOD ALT-11 AST-18 LD(LDH)-196 AlkPhos-84 TotBili-0.4 [2144-3-30] 05:12PM BLOOD Type-ART pO2-213* pCO2-41 pH-7.26* calTCO2-19* Base XS--8 Intubat-NOT INTUBA . OTHER PERTINENT LABS [2144-4-10] 06:30AM BLOOD WBC-24.2* [2144-4-11] 06:16AM BLOOD WBC-15.3* [2144-4-12] 07:16AM BLOOD WBC-9.5 [2144-4-16] 09:45AM BLOOD 25VitD-6* [2144-4-16] 09:45AM BLOOD PTH-1669* [2144-4-20] 06:00AM BLOOD Valproa-13* [2144-4-21] 08:50AM BLOOD ALT-16 AST-19 LD(LDH)-193 AlkPhos-97 TotBili-0.2 [2144-3-30] 10:00AM BLOOD CK-MB-5 cTropnT-0.14* [2144-3-31] 02:56PM BLOOD CK-MB-4 cTropnT-0.16* [2144-4-2] 09:40PM BLOOD CK-MB-3 cTropnT-0.15* . DISCHARGE LABS [2144-4-23] 07:38AM BLOOD WBC-6.8 RBC-2.69* Hgb-8.6* Hct-28.6* MCV-106* MCH-32.1* MCHC-30.2* RDW-15.5 Plt Ct-433 [2144-4-23] 07:38AM BLOOD Glucose-90 UreaN-31* Creat-5.5* Na-130* K-4.4 Cl-90* HCO3-28 AnGap-16 [2144-4-23] 07:38AM BLOOD Calcium-8.9 Phos-5.9* Mg-3.1* . MICROBIOLOGY BLOOD CULTURES ([3-30], [4-5], [4-9], [4-11]) - FINAL NEGATIVE BLOOD CULTURES ([4-20], [4-21]) - NGTD URINE CULTURE ([4-10]) - FINAL NEGATIVE . IMAGING . [3-30] CXR IMPRESSION: 1. Right upper lobe pneumonia. 2. Right middle lobe opacity might represent pneumonia versus atelectasis. 3. Left-sided pleural effusion with concurrent atelectasis and peripheral opacity which might represent scarring although superimposed pneumonia cannot be excluded. . [4-5] CXR FINDINGS: As compared to the previous radiograph, the left pleural effusion and subsequent areas of atelectasis at the left lung base have minimally decreased in severity. Also decreased in severity is the perihilar right parenchymal opacity. Unchanged appearance of the cardiac silhouette. Unchanged alignment of the sternal wires. . [4-11] LUE LENI IMPRESSION: No drainable collection identified. Peripheral echogenic debris seen at the region of the AV fistula, suggestive of nonoclusive thrombus. Additional structure which has the appearance of a graft in the region of the arm with internal echogenic debris and lack of vascular flow raising the possibility of thrombosis; however, dedicated vascular ultrasound in the vascular lab is suggested if further evaluation is desired. . [2144-4-12] CT CHEST FINDINGS: There are mild new tree-in-[Male First Name (un) 239] centrilobular opacities in the right upper lobe (3:22), in keeping with infection. Since the prior CT in [2142-10-19], there has been interval decrease in size of the rounded atelectasis in the lingula and left lower lobe. There has also been slight decrease in the left-sided loculated pleural effusion. There is persistent to slightly increased linear atelectasis at the left lung base and a new focus of linear atelectasis in the right lung base. There has been no interval change in the size of the 5-mm lung nodule in the right middle lobe adjacent to the horizontal fissure. The airways are patent to the subsegmental levels. The thyroid is grossly unremarkable. There is no hilar or mediastinal lymphadenopathy. Mild, stable cardiomegaly. There is no pericardial effusion. There is stable dense calcification within the coronary arteries. The patient has had a sternotomy and the sternal wires are unchanged. Limited evaluation of the upper abdomen without contrast demonstrates multiple small calcified gallstones, similar to previous. Bilateral adrenal thickening is similar to previous. OSSEOUS STRUCTURES: There is multilevel degenerative change within the thoracic spine with large Schmorl's nodes, slightly progressed in the interval. There is vacuum phenomenon at multiple disc levels. The T8 and T9 vertebral bodies are again fused. No worrisome focal osseous lesions. No fractures. IMPRESSION: 1. Interval development of tree-in-[Male First Name (un) 239] opacities in the right upper lobe, consistent with infection. 2. Interval decrease in the lingula and left lower lobe rounded atelectasis. 3. Interval decrease in the size of the left pleural effusion. . [4-15] POST-PACEMAKER CXR (PA/LAT) The heart is moderately enlarged. A right-sided pacemaker generator pack projects a single lead into the right ventricle. Multiple sternal wires and mediastinal clips denote prior cardiac surgery. The aorta is mildly calcified and moderately tortuous. Central pulmonary vessels are engorged, but there is no overt edema. A small left pleural effusion is again seen. There is left lower lobe rounded atelectasis. A moderate hiatal hernia is present. IMPRESSION: Right-sided pacemaker projecting a lead into the right ventricle. . . STUDIES . [3-30] EKG Rate PR QRS QT/QTc P QRS T 58 198 166 500/496 52 -76 98 Sinus rhythm, rate 100, as well as atrial pacing as recorded in the lead II rhythm strip, complexes three and four with capture and A-V conduction with inappropriate sensing. There is A-V Wenckebach. Right bundle-branch block. Left anterior fascicular block. Compared to the previous tracing of [2144-3-30] evidence of atrial pacing, while the atrial morphology has changed and there is A-V Wenckebach. Followup and clinical correlation are suggested. . [3-31] EKG Rate PR QRS QT/QTc P QRS T 66 158 178 466/476 76 -70 118 Sinus rhythm with premature ventricular complexes. Right bundle-branch block with left anterior fascicular block. Left ventricular hypertrophy with ST-T wave changes consistent with left ventricular hypertrophy. Compared to the previous tracing of [2144-3-30] frequent ectopy is now appreciated. . [4-1] FISTULOGRAM/THROMBECTOMY/STENTING/BALLOON DILATATION 1. Successful mechanical thrombectomy of the thrombosed loop AV graft of the left upper extremity. 2. Stenting of the moderate to high-grade stenosis at the graft vein anastomosis using FLAIR and Fluency covered stents. 3. Successful balloon angioplasty of the central venous stenosis near the junction of the left subclavian and axillary vein up to 12 mm. 4. Successful balloon angioplasty of the mild-to-moderate narrowing at the arterial anastomosis of the AV loop graft. . [2144-4-10] ECHO The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with basal inferior hypokinesis. The remaining segments contract normally (LVEF = 50%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. Minimal calcific aortic stenosis. Brief Hospital Course: 72M w/ HD-dependent ESRD [2-20] lithium toxicity & interstitial nephritis & CAD s/p CABG [2141] admitted for PNA and hyperkalemia; hospital course complicated by PEA arrest x2 & 2:1 AV block prompting pacemaker placement, then by decompensated bipolar disorder (manic type). #[Hospital 7502] health care associated: Pt was initially admitted to the hospital because he was found to have hypoxia to the 70s at the outpatient HD/transplant surgical center. No fever, cough or leukocytosis on admission. CXR showed right upper and right middle lobe pneumonia. As he was a dialysis patient, he was treated for HCAP with vanc/levo/aztreonam. He improved on this treatment, but following PEA arrest (see below) he received a second course of antibiotics (per ID consult recommendations) in the ICU with vanc/cefepime/flagyl because of rising leukocytosis and new pattern of consolidations on chest xray and chest CT several days later. Note: pt was intubated for airway protection during cardiac code, not for his pneumonia. Antibiotics completed before discharge. Patient asymptomatic and normoxemic without supplemental oxygen for several days prior to discharge. #Hyperkalemia/PEA arrest/Heart Block Patient was admitted to the MICU and taken for emergent dialysis due to hyperkalemia. During dialysis he was noted to have bradycardia without perfusion along with non-conducted P waves. He was coded for bradycardic PEA for 4 minutes with return of circulation and was intubated for airway protection. He was transcutaneously paced, transferred to the CCU, and then had a transvenous pacer placed. It was assumed that his PEA arrest was related to toxic metabolic etiology due to lack of recent dialysis treatment and Effexor held due to possible contribution to conduction disorders. Following HD, electrolytes normalized and EKG showed 1:1 conduction so a pacer was not placed as it was felt that the patient's PEA was related to electrolyte disarray. However, upon transfer back to the MICU patient had a second episode of PEA with again 2:1 A:V conduction noted with normal electrolytes. His baseline EKG showed RBBB with LAFB and EP study on [4-6] showed that the patient did have an infra-hisian block with pacing at 440ms without VA conduction. Therefore, a permanent pacemaker without ICD was placed on [2144-4-14] ([Company 1543] Sensia single chamber pacer) without complications. Patient had no cardiac complications following pacer placement. # BIPOLAR DISORDER Pt carries hx bipolar disorder and has been taking effexor chronically. During this admission, he developed prominent manic behaviors which interfered with his care. Given the sudden onset of his symptoms and their severity, he was initially favored to have acute metabolic encephalopathy from inadequate dialysis. Psychiatry consultation was obtained and favored underlying executive dysfunction with component of mania. Reversible causes of delirium were ruled out. Patient was placed on standing haldol and depakote for control of agitation and mania. Psychiatry consult and patient's outpatient therapist (also his HCP) both recommended inpatient psychiatric admission for symptom control/stabilization after the pt was medically stable. Patient was ultimately discharged to an inpatient Psychiatric facility. . # HD-DEPENDENT end stage renal disease/Thrombosis of AV fistula: Pt found to have thrombus in his LUE AVF on [3-28]. Planned outpatient thrombectomy unable to be performed because he was admitted for hypoxia instead. Received urgent HD via a temporary line on admission, with cardiac complications as described above. Temp line removed and HD re-initiated via LUE AVF after successful operative thrombectomy and balloon dilation on [4-1]. L arm fistula accessed successfully during dialysis for several sessions thereafter. During subsequent HD sessions, pt occasionally required additional haldol for mania symptoms. . #QTc PROLONGATION Admission EKG showed QTc elevated to 500, likely combination of medication effect and electrolyte abnormalities. QTc stabilized at 460-480 on stable haldol dose of 1.5 mg [Hospital1 ]. Pt had daily monitoring EKGs while inpatient. . #CAD s/p CABG: Patient has known CAD s/p CABG 3 years ago. Continued home medications: metoprolol succinate 25 QD, simvastatin 20 [Last Name (LF) 244], [First Name3 (LF) ] 81 mg QD. . #POOR DENTITION Patient partially edentulous. Received dental examination inpatient prior to pacemaker placement. Dentist thought no pre-procedure extractions were necessary, but recommended non-urgent removal of teeth #9 and #27. Patient prefers to go to [Hospital1 3278] Dental after discharge. . #BPH Continued doxazosin . #HISTORY MRSA INFECTION Patient has had three negative MRSA swabs - [2144-4-1], [2143-3-3], and [2141-1-19] - since MRSA wound infection in [2140-12-19]. . TRANSITIONAL ISSUES . AT INPATIENT PSYCH FACILITY RECOMMEND INTERNAL MEDICINE CONSULT AT INPATIENT PSYCH FACILITY. 1. DIALYSIS - continue as before. Monitor VS/fistula site. 2. MULTIPLE CARDIAC ISSUES - to be followed-up by Dr. [Last Name (STitle) ] at appt in 1 month. 3. RISK OF RECURRENT PNA. Pt's pneumonia treated twice during this admission. Recommend repeat CXR in [4-24] weeks to assess for full interval resolution. 4. TOOTH EXTRACTIONS. Please assist patient in scheduling appt w/[Hospital1 3278] Dental for extractions. 5. VALPROATE MONITORING - goal level 50-100. Please recheck valproate trough weekly. . AT [Hospital1 1501] AFTER INPATIENT PSYCH DISCHARGE 1. PLEASE FOLLOW-UP TRANSITIONAL ISSUES ABOVE 2. OUTPATIENT PSYCH NEEDS Consider calling upon [Location (un) 511] Geriatrics, a psychiatric support group that visits patients in rehab facilities. They can help establish outpatient psychiatry for management of bipolar disorder symptoms. Medications on Admission: Aspirin 81 mg daily (on dialysis days takes after HD) Doxazosin 8 mg qhs Senna [Hospital1 ] prn Tylenol 325 mg prn pain/temp Vit B complex 1 tab daily (on dialysis days takes after HD) Simvastatin 20 qhs Nephrocaps [Hospital1 ] Colace 1 cap [Hospital1 ] Seroquel 25 mg [Hospital1 ] Sevelamer 1600 mg tid with meals Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:0 2. doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:60 Tablet(s) Refills:0 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. Disp:60 Tablet(s) Refills:0 4. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain: max dose 3 g per day. Disp:90 Tablet(s) Refills:0 5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). Disp:60 Tablet(s) Refills:0 6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:0 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 8. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 9. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:270 Tablet(s) Refills:0 10. haloperidol 0.5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:0 11. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 12. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:30 Tablet Extended Release 24 hr(s) Refills:0 13. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 14. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK (MO) for 5 doses. Disp:5 Capsule(s) Refills:0 15. haloperidol 0.5 mg Tablet Sig: Two (2) Tablet PO at bedtime. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [First Name8 (NamePattern2) 1495] [Doctor First Name ] Discharge Diagnosis: End stage renal disease Multilobar pneumonia Complete heart block AV fistula thrombosis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Known lastname ], You were admitted to the hospital for pneumonia, diagnosed after you were found to have low oxygen levels at the AV care surgical center. You received two courses of antibiotics and were doing well, without breathing difficulty or cough by the time you left. A number of additional issues arose during your hospitalization: 1. You had a successful procedure to remove the clot from your dialysis fistula. 2. Your heart went into life-threatening rhythms twice. We were able to stabilize you and get your heart beating again. You received a pacemaker to prevent it from happening again. 3. You developed symptoms of mania, part of your bipolar disorder. You were seen regularly by a psychiatrist who changed some of your medications. Your manic symptoms continued, so we felt you would benefit from an inpatient psychiatric program before going back to your nursing facility. Your therapist and health care proxy [Name (NI) 1158] [Name (NI) 96334] agreed. 4. You were seen by a dentist who was concerned that you have two infected teeth that need to be pulled. We made the following changes to your medications STOP EFFEXOR (VELAFAXINE) STOP AMLODIPINE START HALDOL, TAKE 1.5 MG TWICE DAILY plus 1 mg before BEDTIME START DEPAKOTE, TAKE 500 MG TWICE DAILY START CINACALCET 30 MG DAILY START VITAMIN D one 50,000 UNIT TABLET WEEKLY FOR 5 WEEKS (MONDAYS) DECREASE METOPROLOL SUCCINATE TO 25 mg DAILY INCREASE SEVELAMER TO 2400 mg three times daily with meals Please review your medications with your doctor at your next appointment. Followup Instructions: CARDIOLOGY FOLLOW-UP Department: CARDIAC SERVICES When: THURSDAY [2144-5-21] at 1 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 11899], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . When you leave the psych facility and get back to your nursing facility, you need to make follow-up PCP and dental appointments. Please ask them to call to help you make appointments: . Name: [Last Name (LF) ],[First Name3 (LF) ] L. Location: [Hospital1 ] PRIMARY PHYSICIANS Address: [Street Address(2) ], [Apartment Address(1) 22976], [Location (un) ],[Numeric Identifier 6809] Phone: [Telephone/Fax (1) 8894] . [Hospital1 10915] School of Dental Medicine [Location (un) 96445], [Numeric Identifier 4809] Main Phone Number ([Telephone/Fax (1) 96446] . YOU NEED DIALYSIS EVERY TUESDAY, THURSDAY AND SATURDAY. DO NOT SKIP - A SINGLE MISSED DIALYSIS SESSION CAN BE LIFE-THREATENING FOR YOU. While you are at [Hospital3 ] you will get dialysis right there. After you return to your nursing facility you will resume regular dialysis sessions as before.	[ "600.00", "585.6", "276.7", "E878.2", "426.52", "285.21", "427.5", "996.73", "403.91", "444.89", "582.89", "E939.8", "426.0", "427.89", "V45.81", "296.40", "507.0", "794.31", "348.30", "486" ]	icd9cm	[ [ [] ] ]	[ "37.26", "96.71", "00.40", "39.90", "37.71", "38.95", "39.95", "00.46", "37.82", "88.49", "39.50", "96.04" ]	icd9pcs	[ [ [] ] ]	20759, 20848	12643, 18512	278, 406	20980, 20980	5312, 12620	22767, 24010	4052, 4090		18893, 20736		20869, 20959		18538, 18870				21165, 22744											3647, 3870		4105, 5293																										231, 240							434, 2860											20995, 21141						3296, 3624	3886, 4036
32,027	156,232	14132	Discharge summary	report	Admission Date: [2183-2-2] Discharge Date: [2183-2-16] Date of Birth: [2118-12-26] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4111] Chief Complaint: Enterocutaneous fistula Major Surgical or Invasive Procedure: [2183-2-4]:Exploratory laparotomy, lysis of adhesions, 4 hours, resection of transverse colon and colocolostomy, enteroenterostomy, closure of enterostomies (2), feeding jejunostomy and repair of incisional hernia. History of Present Illness: Mr. [Known lastname 42097] is a pleasant gentleman who originally underwent an effective gastric bypass surgery and subsequent herniorraphy by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3175] at [Hospital6 ] in [8-29] and was doing well until [2181-10-28] when, by his account, he had a perforation of the small intestine that required emergent surgical repair at St. [Hospital 11042] Hospital in [Location (un) 8117], NH. This was complicated by an extended ICU stay for sepsis and enterocutaneous fistula that he has been dealing with ever since. He was started on TPN in [Month (only) 956] of this year, and the size of the fistula has decreased somewhat but continues to drain approximately 300 cc a day from a small midline opening. Currently he is on a full diet in addition to TPN 12 hrs a day. His main complaint is irritated and painful skin surrounding the fistula site, and he also complains of dumping syndrome, which manifests as general malaise, nausea, and abdominal discomfort after any kind of oral intake. He denies any diarrhea/constipation or changes in urinary habits. His weight has been stable. He is referred to Dr. [Last Name (STitle) 957] from Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at St. [Hospital 11042] hospital for fistula repair and reversal of gastric bypass. Past Medical History: HTN, fungal infection of right eye, TPN related hyperglycemia. No other surgeries. Social History: Pt is an ex-smoker, quit in [2160]. Occasional caffeine use. Denies EtOH and recreational drug use. Lives in [Location 8117], NH with his wife, and works as a logistics manager for the airforce. Family History: Noncontributory Physical Exam: GEN: Well, NAD, A&O CV: RRR, No Rubs/Gallops/Murmurs RESP: Lungs clear to auscultation bilaterally ABD: Soft, Non-tender. Sterile surgical dressing intact over midline incision. JP drains x2 draining sero-sanguinous fluid. EXT: No edema, resolving erythema at L antecubital fossa. Pertinent Results: Surgical Pathology SPECIMEN SUBMITTED: TRANSVERSE COLON, OLD SCAR, TRANSVERSE COLON. Procedure date Tissue received Report Date [2183-2-4] [2183-2-4] [2183-2-14] DIAGNOSIS: 1. Colon, transverse, excision (A-D): Colonic tissue with submucosal hemorrhage intramural granulation tissue and serosal acute inflammation consistent with a fistulous tract. 2. Unremarkable lymph nodes (two examined). Skin, "old scar," excision (E): Skin with acute and chronic inflammation, ulceration, and scar. Brief Hospital Course: Pt was admitted to the Surgical service on [2183-2-2]. On [2183-2-3] pt was prepared for surgery with a bowel prep of Neomycin and Erythromycin. Chest and abdomen was washed with Hibiclens the evening prior to surgery. On [2183-2-4] pt was taken to the OR for fistula takedown. Pt tolerated the procedure well. Two JP drains were placed extra peritoneally. Pt was placed on Ancef and Flagyl perioperatively. A morphine PCA was used for post-operative pain control. Tube feedings were started on POD#1. The Foley catheter and NGT were removed on POD#2, the pt was straight cathed x1 on POD#2 for failure to void after Foley catheter was removed, however pt was able to void after POD#2. Tube feeds were advanced on POD#[4-1]. On POD#5 the pt had two bowel movements, the pt was started on a soft solid PO diet and the PCA was discontinued. The pt experienced an episode of emesis with increasing abdominal pain at which point tube feeds were discontinued, the pt was once again made NPO and placed on IV pain medication. An abdominal X-Ray at this time was consistent with an early ileus. Tube feeds were restarted on POD#6 and advanced. However on POD#6 the pt once again experienced episodes of emesis accompanied by abdominal pain, and tube feeds were again discontinued. Pt continued to have bowel movements during this time. TPN was begun on POD#7, and tube feeds were restarted on POD#8. TPN continued and tube feeds were advanced. Pt was discharged on POD#11 tolerating tube feeds at goal. Pt was discharged with VNA services for tube feeds, TPN, and daily emptying of JP drains. Pt was instructed to conservatively begin a clear liquid diet as tolerated at home. Medications on Admission: amlodipine 5mg Qday Discharge Medications: 1. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for insomnia. Disp:16 Tablet(s) Refills:0 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 4. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:60 Tablet(s) Refills:2 5. Hydrocortisone 1 % Ointment Sig: One (1) Appl Topical QID (4 times a day). 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:60 Capsule(s) Refills:2 7. Enteric Tube Feeds Tubefeeding: Impact 1/2 strength; Starting rate: 60 ml/hr; Goal rate: 60 ml/hr Residual Check: q4h Hold feeding for residual >= : 100 ml Flush w/ 50 ml water q8h 8. TPN TPN as indicated on attached TPN formulation. Adjust as necessary. Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Enteric small bowel fistula and colonic fistulas Post-operative ileus Discharge Condition: Good. Discharge Instructions: .Please call your Dr. [Last Name (STitle) 957] for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * If you are nauseous and 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 becoming progressively worse * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. A large amount of swelling or bruising An increase redness or drainage of the incision Bright red blood or foul smelling discharge coming from the incision Difficulty urinating * Any serious change in your symptoms, or any new symptoms that concern you. Additional Instructions Dressings: If the dressing from the operating room is still on, you should leave it on until it is removed by Dr. [Last Name (STitle) 957] in the office. Activity: You can start getting back to your routine as soon as you feel able. Just take it easy at first. The following tips may help:Take short walks to improve circulation. If you were able to climb stairs before your surgery, you may continue to climb stairs; this will not harm your incision. You may start some light exercise when you feel comfortable. Lifting: For a period of six weeks, please do not lift anything heavier than ten (10) pounds, which is as large as [Initials (NamePattern4) ] [Last Name (NamePattern4) 86] telephone book. It will take about six (6) weeks for your incision to heal.; at the end of six (6) weeks your incision will be as strong as it will be a year from now. Fatigue: It is normal to experience fatigue for 2-3 weeks days after your surgery. The more exercise and activity you re involved in, the better you will be and the quicker you will recover. Driving: You should not drive for 1-2 weeks, it is important to allow the incision to heal before you drive. Do not drive until you have stopped taking pain medication or until your reflexes have returned to [Location 213]. You need to feel that you could respond in an emergency. Dr. [Last Name (STitle) 957] will inform you at your hospital follow-up appointment when it is safe for you to resume driving. Diet: You diet during this hospitalization was a . Please continue to eat healthy, high-fiber foods and drinks plenty of fluids. Constipation: To prevent constipation that can be associated with the use of pain medication, please continue to take Colace (stool softener) and Metamucil. You may also stop these medications if you are having loose stools. Followup Instructions: Provider:[First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ],MD Phone:[Telephone/Fax (1) 2359] Date/Time: [2183-2-26] 9:45 You have an appointment to have a swallowing study with XRAY before your appointment with Dr.[Last Name (STitle) 957]. Provider: [Name10 (NameIs) 326] UPPER GI (TCC) RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2183-2-26**] 8:30	[ "560.1", "998.6", "553.21", "997.4", "568.0", "788.20", "V45.86", "564.2", "515", "401.9" ]	icd9cm	[ [ [] ] ]	[ "46.74", "46.76", "96.6", "46.39", "53.51", "44.5", "45.74", "99.15", "54.59" ]	icd9pcs	[ [ [] ] ]	5834, 5886	3212, 4899	338, 559	6000, 6008	2656, 3189	8826, 9227	2322, 2339		4969, 5811		5907, 5979		4925, 4946				6032, 8803													2354, 2637																										275, 300							587, 1977																	1999, 2084	2100, 2306
14,491	169,124	17739	Discharge summary	report	Admission Date: [2147-5-19] Discharge Date: [2147-5-24] Date of Birth: [2147-5-19] Sex: M Service: Neonatology HISTORY: The patient is a 1,770 gram male infant born by stat cesarean section for fetal bradycardia at 30-6/7 weeks gestation to a 29-year-old gravida 3, para 0 now 1 mother. The pregnancy was unremarkable until [2147-5-15] when the mother presented to [Hospital3 ] for increased blood pressure and proteinuria. She was transferred to [Hospital1 346] and was treated with magnesium sulfate and betamethasone. The morning of admission the mother developed vaginal bleeding and fetal bradycardia was noted. Therefore, a stat cesarean section was performed. The infant emerged limp and without spontaneous respiratory effort. He was given bag mask ventilation with good response. Apgar scores were 6 at one minute and 8 at five minutes. PRENATAL SCREENS: O+, hepatitis B surface antigen negative, RPR nonreactive, rubella immune. ADMISSION PHYSICAL EXAMINATION: The birth weight was 1,770 grams. The patient was in mild to moderate respiratory distress. He was a nondysmorphic male. Anterior fontanel was soft, open and flat. The ears and eyes were normally placed. The palate was intact. The oropharynx was benign. Neck was supple without masses or defects. The lungs were coarse bilaterally with moderate retractions. The cardiovascular examination revealed S1 and S2 regular, no murmurs, 2+ femoral pulses. He was warm and well perfused. The abdomen was benign, flat, nontender, nondistended, no hepatosplenomegaly. He had a normal male phallus and bilaterally descended testes. The anus was patent and normally placed. Hips were stable without clunk. The extremities were normal in appearance. The skin was without lesions. The neurological examination was appropriate for age with normal tone and strength and appropriate reflexes. HOSPITAL COURSE: 1. Cardiovascular: The patient remained cardiovascularly stable throughout the admission. He was noted to have some apnea and bradycardic spells of prematurity and was therefore started on caffeine. With the initiation of caffeine therapy the patient has had no more apnea or bradycardic events. 2. Respiratory: The patient was initially started on nasal prong CPAP at 6 and required additional oxygen to 35%. However by 24 hours he transitioned to low-flow nasal cannula and on day of life five transitioned to room air where he currently remains. 3. Fluids, electrolytes and nutrition: The patient was initially maintained on intravenous fluids only and when his respiratory distress resolved he was transitioned to enteral feeds. The morning of transfer his IV came out so he has just been advanced to 120 cc per kg per day of PE-20 and his tolerating these PG feedings without difficulty. Last set of electrolytes on [5-22], DOL3: Na 145, K 4.3, Cl 110, tCO2 25. Discharge Wt 1645 gms. 4. Hematology: His admission complete blood count was notable for a white count of 11.8, 25 polys and no bands. Hematocrit was 45, platelet count 270. He developed physiologic hyperbilirubinemia (peak bili 8.6/0.3 on [5-22], DOL3)for which he was treated with a single phototherapy. His most recent bilirubin was 6.6 on day of life six, the day of discharge, and his phototherapy was discontinued. He will need a rebound bilirubin level in am. 5. Infectious disease: Blood culture was sent but he was never started on antibiotics. The blood culture remained sterile. He was noted to have an erythematous perianal rash and for this was started on Nystatin powder. The parents were updated throughout the admission and a family meeting was held on [2147-5-23]. 6. Sensory: The patient has not had an eye examination or hearing test. CONDITION ON DISCHARGE: Good. DISPOSITION: To [Hospital1 2436] Special Care Nursery. NAME OF PEDIATRICIAN: [Location (un) 25121] Air Force Base Pediatrics. CARE AND RECOMMENDATIONS: Feeds at discharge are PE-20 currently at 120 cc per kg per day due to advance 15 cc per kg per day to a total of 150 cc per kg per day. DISCHARGE MEDICATIONS: Caffeine 12 mg pg q day. He has not had his [5-24] dose. STATE NEWBORN SCREENING STATUS: He is due to have his state screen sent today. IMMUNIZATIONS: Not yet received. Synagis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following criteria: 1. Born at less than 32 weeks. 2. Born at 32-35 weeks with plans for day care during RSV season with a smoker in the household, or with preschool age siblings. 3. With chronic lung disease. Influenza vaccination should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. Before this age, the family and other caregivers should be considered for immunization against influenza to protect the infant. DISCHARGE DIAGNOSES: 1. Prematurity at 30-6/7 weeks. 2. Rule out sepsis, off antibiotics. 3. Apnea and bradycardia of prematurity. 4. Hyperbilirubinemia. 5. Feeding immaturity. [First Name8 (NamePattern2) 36400] [Name8 (MD) ], M.D. [MD Number(1) 37201] Dictated By:[Last Name (NamePattern1) 44694] MEDQUIST36 D: [2147-5-24] 09:35 T: [2147-5-24] 09:51 JOB#: [Job Number 49311]	[ "779.3", "770.81", "765.17", "V30.01", "779.81", "778.8", "782.1", "765.25", "774.2" ]	icd9cm	[ [ [] ] ]	[ "96.6", "93.90", "99.83" ]	icd9pcs	[ [ [] ] ]								4973, 5397	4149, 4952					1935, 3790							3987, 4125																							1026, 1917																																						3815, 3960
17,738	128,883	22811	Discharge summary	report	Admission Date: [2174-3-10] Discharge Date: [2174-3-14] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1850] Chief Complaint: hematocrit drop and melena Major Surgical or Invasive Procedure: Colonoscopy EGD / Colonoscopy History of Present Illness: 83 yo male w/hx of CAD s/p recent PTCA, CHF (EF30-35%), PVD s/p CEA and AAA repair, prostate CA s/p radiation tx, afib off coumadin admitted for falling hematocrit and melena. Pt was recently hospitalized [Date range (1) 58978] for GIB which was managed conservatively since EGD at OSH was neg and colonoscopy revealed only nonbleeding polyps and tics. During that hospitalization he had elevated troponins so he was taken to catherizationa and his RCA and L circumflex arteries were stented with plan for one month of plavix. Plan was made for follow-up with general surgery for a large sessile polyp in the ascending colon which could not be removed with colonocopy and was thought to be contributing to his bleeding. During follow up appointments with his PCP on [2-25] and ?[3-4] he was transfused 1 unit PRBC's on each of those days for low Hct. Pt was seen on day of admission by a General Surgeon Dr. [Last Name (STitle) 19122] who felt the pt looked pale and referred him to the ED. He reported generalized weakness and mild DOE but otherwise was feeling well. In the ED his vital signs were stable although his Hct remained stable despite 1 unit PRBC transfusion so he was transfused a second unit and he was admitted. Past Medical History: 1.)Coronary artery disease, s/p hepacoat stents to RCA and Lcx in [1-19] 2.)AAA s/p repair [2164] (aortofemoral bypass) 3.)Cerebrovascular disease with lacunar infarcts, s/p left CEA 4.)PVD 5.)CHF 6.)Afib on warfarin until admission 7.)Prostate CA 8.)Chronic dizziness of [Last Name (un) 5487] etiology Social History: Smoked for 50yrs (approximately 1ppd). Has [3-18] drinks per week. Lives with wife [Name (NI) 382] and has supportive local family. Family History: Pt has son with DM, brother with MI in 50's. Physical Exam: T 97.1 BP 115/51 Hr 93 RR 21 O2 Sat 100% [Female First Name (un) ] Gen-mild respiratory distress HEENT-right neck scar, no ant or post cerv LAD, arcus senilis bilat, MMM, oropharynx clear CV-Irreg irreg rhythm, nS1S2, [3-20] SM at apex not radiating to the axilla Lungs-mild bibasilar crackles Abdomen-soft, NT, ND, no organomegaly, NABS Extrem-no edema or tenderness Rectal-dark guaiac positive stool Pertinent Results: [2174-3-10] 11:22PM HCT-30.6* [2174-3-10] 05:17PM HCT-29.6* [2174-3-10] 11:50AM HCT-31.3* [2174-3-10] 07:30AM GLUCOSE-106* UREA N-37* CREAT-1.4* SODIUM-141 POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-25 ANION GAP-13 [2174-3-10] 07:30AM CK(CPK)-54 [2174-3-10] 07:30AM cTropnT-<0.01 [2174-3-10] 07:30AM IRON-78 [2174-3-10] 07:30AM calTIBC-507* VIT B12-254 FOLATE-13.0 FERRITIN-55 TRF-390* [2174-3-10] 07:30AM WBC-9.8 RBC-3.18* HGB-9.0* HCT-27.9* MCV-88 MCH-28.2 MCHC-32.2 RDW-16.4* [2174-3-10] 07:30AM NEUTS-76.8* BANDS-0 LYMPHS-15.9* MONOS-5.0 EOS-2.0 BASOS-0.4 [2174-3-10] 07:30AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-2+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+ TARGET-OCCASIONAL [2174-3-10] 07:30AM PT-13.7* PTT-23.6 INR(PT)-1.2 [2174-3-10] 01:15AM CALCIUM-8.4 PHOSPHATE-3.4 MAGNESIUM-2.2 [2174-3-10] 01:15AM WBC-10.2 RBC-3.23* HGB-9.3* HCT-28.4* MCV-88 MCH-28.7 MCHC-32.6 RDW-16.4* [2174-3-10] 01:15AM NEUTS-75.0* BANDS-0 LYMPHS-17.5* MONOS-4.5 EOS-2.8 BASOS-0.2 [2174-3-10] 01:15AM HYPOCHROM-OCCASIONAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL [2174-3-10] 01:15AM PLT SMR-NORMAL PLT COUNT-273 [2174-3-9] 11:15PM URINE HOURS-RANDOM CREAT-27 SODIUM-59 POTASSIUM-55 CHLORIDE-89 TOTAL CO2-LESS THAN [2174-3-9] 08:30PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.009 [2174-3-9] 08:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2174-3-9] 07:00PM GLUCOSE-122* UREA N-41* CREAT-1.5* SODIUM-136 POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-24 ANION GAP-14 [2174-3-9] 07:00PM IRON-37* [2174-3-9] 07:00PM calTIBC-566* VIT B12-289 FOLATE-12.1 FERRITIN-57 TRF-435* [2174-3-9] 07:00PM WBC-9.0 RBC-3.26* HGB-9.5* HCT-29.3* MCV-90 MCH-29.0 MCHC-32.3 RDW-15.6* [2174-3-9] 07:00PM NEUTS-67.6 BANDS-0 LYMPHS-24.5 MONOS-3.6 EOS-3.9 BASOS-0.4 [2174-3-9] 07:00PM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL [2174-3-9] 07:00PM PLT COUNT-322# [2174-3-9] 07:00PM PT-13.4 PTT-22.7 INR(PT)-1.1 CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST 1. Interval development of a small amount of fluid in the left paracolic gutter, surrounding the spleen and liver, and adjacent to some loops of small bowel in the left abdomen and adjacent to the hepatic flexure. There is no abnormality of the adjacent bowel that is identified. No free air or spillage of contrast is detected. The findings may correlate non-specifically with recent colonoscopy. The visualized main proximal portions of the aortic branches are patent. 2. Slight gallbladder wall thickening and non-specific stranding about the gallbladder and pancreas. 3. Small bilateral pleural effusions. LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [2174-3-13] 10:43 AM 1. Echogenic liver consistent with fatty infiltration. However, other forms of liver disease and more advanced liver disease including fibrosis/cirrhosis cannot be excluded on this study. 2. No intra- or extra-hepatic biliary ductal dilatation. 3. Slight gallbladder wall thickening, but no wall edema or gallbladder distention. Slight wall thickening could be seen in an edematous state. If there is strong suspicion of cholecystitis, biliary scintigraphy could be helpful. CHEST (PORTABLE AP) [2174-3-12] 7:25 AM There is cardiomegaly with tortuosity of the aorta and slight pulmonary, vascular engorgement, possibly related to CHF or fluid overload. There is flattening of the diaphragms consistent with COPD. Brief Hospital Course: 83 yo male w/hx of CAD s/p recent PTCA, CHF (EF 30-35%), PVD s/p CEA and AAA repair, prostate CA s/p radiation tx, afib- off coumadin admitted [3-9] for falling hematocrit and melena. GI Bleed and Abdominal Pain: Patient recently admitted and had negative EGD with colonoscopy showing only polyps none of which were bleeding. Pt has also known diverticuli although they were also not bleeding on recent scope. Small bowel has never been evaluated since recent CT was without oral contrast and no SBFT performed. Given hx of melena with no BRBPR despite 2 unit Hct drop over the last month, elevated BUN, we were more suspicious of UGI source although EGD neg. Pt was evaluated by surgery in the ED and feel that polyps aren't a likely source of the bleeding and consider the patient a high surgical risk. Patient underwent colonoscopy, and multiple polys were removed without complication. However, one day following colonoscopy, patient became hypotensive and ill-appearing with mild abdominal pain and was transferred to the intensive care unit for closer monitoring for concern of micro-perforation vs. bleed. Of note, CT abdomen/pelvis revealed no free air, however did reveal pericolic fluid of unknown significance as well as some mild gallbladder wall thickening and fat stranding of also unknown significance. Patient underwent surgical evaluation with concern for cholecystitis vs. bowel microperforation. Atrial Fibrillation: Patient was in stable atrial fibrillation throughout hospital course until the evening following transfer to intensive care unit. Patient became acutely tachycardic to 140s-150s, with SBP 90s-100s, and was thought to be in atrial fibrillation with rapid ventricular response secondary to adrenergic stress from infection vs. blood loss. Patient was initially bolused with ~2liters of lactated Ringer's, however, heart rate did not improve, although pressure improved slightly to 110s. Therefore, patient was administered metoprolol 5mg IV X 2, then diltiazem 10mg IV with good effect, and patient's rate came to 110s. Patient's blood pressure, however, was also affected by both medications, and came to high 80s systolic. At that point, it was felt that adequate evaluation of patient's volume status in the form of central venous pressure was necessary, and central line placement was offered to patient. However, at this point, patient began to refuse all medical interventions including foley catheter placement. Coronary artery disease: Patient had recently undergone catheterization with placement of multiple bare metal stents and was initially started on Plavix, however, this was later held due to continued symptomatic GI bleeds. During this hospitalization, patient had no chest pain. ECG showed ST depression in v [3-20] but this is unchanged from previous, and cardiac enzymes were negative. Of note, aggressive managment of patient's episode of AFIB/RVR was undertaken despite no hemodynamic compromise given concerns of demand ischemia. Metabolic Acidosis: mixed gap (lactate) and non gap (ARF/diarrhea) acidosis. ARF/diarrhea likely secondary to dehydration from bowel prep for colonoscopy and over-diuresis with lasix. Patient had elevated lactate concerning for ischemic bowel or bowel perforation from colonoscopy. CT abd neg for free air or ischemic colitis. Of note, patient did have at urinary tract infection concerning for urosepsis, however, following IV hydration, gap acidosis corrected. Despite transfer to the intensive care unit, patient became adamant in his refusal of further interventions, and ultimately decided that he wished comfort management only. This was an appropriate decision as further interventions required for his care would have been fairly aggressive in the setting of poor cardiovascular and hemodynamic status. Furthermore, family members were in attendance and agreed with patient's decision. Therefore, on hospital day 5, patient was discharged home with hospice care. Medications on Admission: Protonix 40mg qd toprol XL 50mg qd Lisinopril 2.5mg qd colace 100mg qd ASA 81mg Lasix 80mg qd KCL 40mEq qd Atorvastatin 40mg qd Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. MSir 10 mg/5 mL Solution Sig: [1-16] mL PO q2 hours as needed for pain. Disp:5 vials Refills:2 3. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for anxiety. Disp:45 Tablet(s) Refills:0 4. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 5. MS Contin 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day for prn : pain days. Disp:60 Tablet Sustained Release(s) Refills:0 6. Ativan 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for anxiety. Disp:30 Tablet(s) Refills:0 7. Lorazepam 2 mg/mL Concentrate Sig: [1-16] ml PO every 4-6 hours as needed for anxiety. Disp:60 units Refills:0 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three times a day for 14 days. Disp:42 Tablet(s) Refills:0 9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day for 14 days. Disp:14 Tablet(s) Refills:0 10. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 13. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day. Disp:30 Tablet(s) Refills:2 15. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. Disp:60 Tablet(s) Refills:0 16. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 17. Reglan 5 mg Tablet Sig: One (1) Tablet PO q4-6 PRN. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: atrial fibrillation, hypotension, metabolic acidosis, abdominal pain, gastrointestinal bleed, acute renal failure Discharge Condition: fair Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: follow up with your primary care physician [First Name8 (NamePattern2) 1176] [Name8 (MD) 1177] MD [MD Number(2) 5799]	[ "414.01", "276.2", "599.0", "562.10", "V45.82", "276.5", "578.9", "V10.46", "584.9", "496", "427.31", "211.3", "428.0" ]	icd9cm	[ [ [] ] ]	[ "99.04", "45.13", "45.42" ]	icd9pcs	[ [ [] ] ]	12362, 12445	6279, 10268	289, 321	12603, 12609	2599, 6256	12758, 12920	2107, 2153		10447, 12339		12466, 12582		10294, 10424				12633, 12735													2168, 2580																										223, 251							349, 1594																	1616, 1934	1950, 2091
41,678	121,237	39319	Discharge summary	report	Admission Date: [2183-6-28] Discharge Date: [2183-7-20] Date of Birth: [2161-11-25] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 371] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Abdominal washout. 3. Ileostomy formation. History of Present Illness: Mr. [Known lastname ] is a 21 yo man with h/o GSW to the RUQ s/p ex lap and partial small bowel resection ([10-21]) who presents with abdominal pain and post-prandial vomiting. . He was in his USOH until 3 weeks ago when he developed crampy abdominal pain, worse with eating. He states the pain would migrate throughout the abdomen, and he has been having fewer bowel movements. The pain worsened and so he came to the ED on [6-26] where a CT abdomen/pelvis revealed a probable ileus. The pain improved with NGT suction and pain medications, however once he started feeling better he took POs against the advice of the surgical staff and left AMA on [6-27]. . At home he had a little ginger ale and a small amount of food, after which he experienced increasing abdomial pain and bilious vomiting, so he returned to the ED. He had a small loose BM yesterday and a small amount of gas pass at that time however since then has had no BM or flatus. Of note he also has noticed some tenderness when he touches his scrotum which has been noted over the course of the day. No penile discharge or burning on urination. . In the ED initial VS were T 98.8, P 106, BP 131/73, R 22, O2 Sat 95% on RA. An NG tube was placed to suction and a KUB again demonstrated probable ileus. He was given 1L of NS, zofran 4mg, and dilaudid 2mg IV. Surgery evaluated the patient. Past Medical History: GSW s/p ex lap and partial small bowel resection Social History: Lives in [Hospital1 189] with his mother. Girlfriend at bedside. No children. Drinks 2 shots of EtOH weekly with coke. Smokes [12-14] PPD of newports for 3 years. Smoke MJ however denies IVDU, cocaine. No other sexual partners. Family History: Noncontributory Physical Exam: VS: T 97.2, BP 100/60, P 42, R 16, 97% RA Gen: NAD HEENT: NC/AT, PEERL, EOMI, MMM Neck: Supple, no JVD, no LAD CV: RRR, +S1/S2, no M/R/G Pulm: CTAB Abd: Decreased BS, soft, large central abdominal scar, mildly TTP diffusely, no gaurding or rebound, no masses palpated, no hepatosplenomegaly Ext: WWP, no edema, pulses 2+ bilaterally Neuro: AAOx3, CNII-XII intact, moving all extremities Pertinent Results: Labs: . . Imaging: [2183-7-19] 05:15AM BLOOD WBC-14.9* RBC-2.40* Hgb-7.8* Hct-23.5* MCV-98 MCH-32.4* MCHC-33.1 RDW-13.1 Plt Ct-552* [2183-7-9] 09:00AM BLOOD Neuts-77* Bands-7* Lymphs-2* Monos-13* Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [2183-7-20] 05:43AM BLOOD Glucose-90 UreaN-10 Creat-0.8 Na-133 K-5.3* Cl-97 HCO3-29 AnGap-12 [2183-7-14] 03:06AM BLOOD TotBili-2.4* DirBili-1.2* IndBili-1.2 [2183-7-20] 05:43AM BLOOD Calcium-9.6 Phos-4.2 Mg-2.0 Brief Hospital Course: Initially he was medically managed for a presumed ileus with bowel rest, ngt, ivf. An NGT clamping trial was attempted and the NGT was discontinued on [7-4]. Reglan was started. Pain has been managed with ketorolac and tylenol. Repeat KUB still consistent with small bowel obstruction vs ileus following NG tube being pulled. Diet advanced to clears, however patient continued to endorse left sided / periumbilical pain, inability to pass flatus, or ability to have bowel movements. Patient developed fevers on [7-5] with Tmax overnight 101.3. Other than left sided periumbilical pain and obstipation/constipation, no focal sources of fever on review of systems. On [7-8] A CT scan demonstrated a questionable bowel perforation with a leak. On [7-8] he was taken to the OR for exploration and lysis of adhesions, small-bowel resection, and ileostomy. They did find an abcess near the anastamosis. The patient was taken to the ICU postoperatively with an open abdomen. On [7-11] he was taken back to the operating room for a washout and partial abdominal closure. He was taken back to the ICU. He was weaned off the ventilator and was doing well. On [2183-7-15] he was taken back to the operating room for complete abdominal closure. His pain was well controlled with a PCA. He was transferred to the floor in good condition. His diet was advanced to regular, which he tolerated well. His foley was discontinued and he voided without assistance. He was ambulating multiple times daily. He did have elevated ileostomy output prior to disharge and was started on immodium which decreased the volume of ileostomy output. Medications on Admission: none Discharge Medications: 1. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [3-18] hours as needed for pain. Disp:12 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: anastamotic leak Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with nausea and vomiting after eating. An x-ray of your abdomen showed that you have an ileus (slowing of your bowels). We placed a tube down your nose and into your stomach to help with this. We later removed the tube and you were able to start eating again. Please continue to advance your diet as tolerated. . You were not taking any medications and we did not start any new ones. . Please see your primary care doctor within the next 1-2 weeks. General Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [4-21] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. Followup Instructions: PCP [Name Initial (PRE) 176] 1-2 weeks ([Hospital 189] Community Health Center) Follow up in the acute care surgery clinic in next Tuesday [7-29]. Please call [Telephone/Fax (1) 600] to make an appointment.	[ "338.18", "309.81", "998.59", "569.83", "564.3", "305.1", "567.22", "560.81", "560.1", "997.4", "V62.0", "V17.49", "276.1", "E878.2", "909.3", "V18.0", "557.9", "569.69", "569.5" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.6", "45.61", "46.20", "54.59", "96.04", "96.07", "54.12", "38.93", "54.63", "96.59" ]	icd9pcs	[ [ [] ] ]	4926, 5001	3075, 4720	329, 404	5061, 5061	2584, 3052	6722, 6950	2144, 2161		4775, 4903		5022, 5040		4746, 4752				5212, 5695										6327, 6699			2176, 2565																								5728, 6311		275, 291							432, 1803											5076, 5188						1825, 1875	1891, 2128
21,537	129,493	21035+21036+21037+57215	Discharge summary	report+report+report+addendum	Admission Date: [2182-5-22] Discharge Date: [2182-7-9] Date of Birth: [2142-12-7] Sex: M Service: MED HISTORY OF PRESENT ILLNESS: This is a 39 year old male with newly diagnosed diabetes with a history of kidney donation, recent septic knee Staph, approximately one week ago, that was treated. Details unknown. Today, he was going to follow- up appointment at medical doctor, where he was found unresponsive in the car in the parking lot. Noted by EMS to be pulseless with mottled skin. Noted at outside Emergency Department to have pulse after intravenous fluids, approximately 500 cc of normal saline. Initial vitals in the Emergency Department at the outside hospital were pulse of 108, blood pressure 131/83, breathing at 28, temperature of 98.8, oxygenating 98 percent on nonrebreather. Course notable for knee bursa aspiration of approximately 10 cc of serosanguinous fluid with gram stain with many gram positive cocci in clusters. He was given one gram of Vancomycin, one gram of Ceftriaxone and 500 mg of intravenous Flagyl. His white blood cell count was 21.2 with a hematocrit of 44, glucose of 387, bicarbonate of 10, anion gap of 28 and creatinine of 2.0. Arterial blood gases was 7.14. PAC02 of 24, PA02 of 90 on four liters of nasal cannula. He was given four liters of fluid, started on insulin drip at five units an hour. An electrocardiogram showed sinus tachycardia at 118 beats per minute, otherwise normal. He was found speaking full sentences, intubated and transferred. In the Emergency Department at [Hospital1 188], initial vitals were temperature of 37.1 degrees C., blood pressure 110/43; pulse of 115; breathing at 12 with 100 percent saturations on ventilation. Urinalysis showed positive ketones and positive glucose. Insulin drip was kept at five units an hour. He was on ventilatory settings with assist control of 800 tidal volume by 16 rate; PEEP of 5, FI02 of 100 percent. He was on Ativan at 2 mg with Propofol drip of 2. Lactate was checked and was 2.4. Right subclavian line was placed. Initially, temperature was 37.2 with a central venous pressure of 12, PEEP of 5, SV02 of 80, heart rate of 119, Map of 85. His blood pressure was 123/66 post 4800 cc of intravenous fluids. Ortho evaluated right knee fluctuance and transferred to Medical Intensive Care Unit. Arterial blood gases at that time was 7.16, PAC02 of 37, PA02 of 181. Respiratory rate was increased from 16 to 20. The patient was actually breathing at 24. Repeat lactate was 1.6. Central venous pressure of 18. Orthopedics did an incision and drainage at the bedside and it showed infectious prepatellar bursitis with gram stain and cultures sent and the patellar tendon was washed. PAST MEDICAL HISTORY: Kidney donor in [2162]. Status post knee arthrocentesis one week prior to admission. ALLERGIES: No known drug allergies. FAMILY HISTORY: Mother with a history of cancer; dad with a history of heart attack; brother with a history of diabetes. MEDICATIONS: None. SOCIAL HISTORY: Brother is [Name (NI) ], contact number at home is [Telephone/Fax (1) 55870], at work is [Telephone/Fax (1) 55871]. No history of tobacco. No history of intravenous drug abuse. Drinks about three to four drinks per day. He works at a supermarket. PHYSICAL EXAMINATION: He was intubated and sedated. Vital signs were blood pressure of 105/91; heart rate of 103; CPP of 18; weighing 120 kg. Head, eyes, ears, nose and throat: Anicteric. Pupils are equal, round, and reactive to light and accommodation. Neck supple. No lymphadenopathy. Pulmonary: Clear to auscultation bilaterally, no wheezes. Cardiovascular: Tachycardia, no murmurs, rubs or gallops. Abdomen: Obese, soft, nondistended, nontender, normoactive bowel sounds. Extremities: No cyanosis, clubbing or edema. Knee: Right knee with bursa puncture wound, fluctuant effusion, warm. Skin: Mottled, improved after intravenous fluids and resuscitation. Neurologic: Intubated, sedated. Spontaneously moving all extremities. LABORATORY DATA: White blood cell count of 23.2; hematocrit of 40.2; platelets of 501; neutrophils 59, bands 30, lymphocytes 5, monos 0. Lactate initially of 2.4, decreased down to 1.5. Chemistry showed a sodium of 138; potassium of 3.1; chloride 102; bicarbonate of 11; BUN 38; creatinine 1.5; glucose of 270. Calcium 8.1, magnesium 2.5, phosphorus 53. Urinalysis showed pH of 5, urobilinogen 4, bilirubin small leukocytes, negative blood, large proteins 30, glucose 100, ketones 50. Chest x-ray showed mild cephalization with pulmonary vascular engorgement. Films of the knee, three views, show no bony structure, no fracture, no effusion. Outside hospital knee aspiration showed many gram positive cocci in clusters, suggestive of staph. HOSPITAL COURSE: Sepsis/Fevers: The patient was declared septic for prepatellar bursitis on day one to two of admission. He was started on protocol and aggressively hydrated. He was also started on Vancomycin and Ceftriaxone for gram positive cocci in cultures, not speciated yet. Outside hospital call had said that the patient had become bacteremic from MSSA. At this time, the patient had Vancomycin discontinued, continue Ceftriaxone, started on Oxacillin on [5-24]. With evidence of bacteremia from an outside hospital cultures and the patient's persistent temperature spikes, there was concern to whether the patient had seated one of his cardiac valves. A TTE was then done, which was negative and then a transesophageal echocardiogram was done which was also negative for endocarditis. With no other clear source of fevers, we considered whether the patient may have had a ventilatory associated pneumonia, versus urinary tract infection versus further seeding of the knee. A urinalysis was initially unremarkable and he was started on empirically on Ceftazidime, Flagyl, both minimally dosed to cover for gram negative rods, pneumonia and aspiration pneumonia on [5-27]. Levorphan and Dobutamine were used transiently for episodes of hypotension that were noted through the initial part of the hospital course. Chest x-rays were taken almost on a daily basis. Left lower lobe pneumonia atelectasis was finally accessed to be atelectasis secondary to body habitus. Ceptaz and Flagyl were discontinued. Ceptaz was also discontinued because a rash had developed after several days of administration. The patient continued to spike fevers, despite continued antibiotics, negative blood cultures, sputum cultures and urine cultures here. The only cultures positive were the cultures taken from the knee site which were MSSA. Lines were changed consistently with cultures sent each time, all returning back negative growth to date. Thoracentesis was sent for culture and gram stain, both negative growth. Liver function tests, amylase and lipase were all within normal limits. With high suspicion for drug fevers in the setting of continued total body rash, we discontinued the Oxacillin and placed the patient on Clindamycin on [6-6]. Infectious disease was consulted on [6-7] and we continued to check peripheral access to assess for drug rash fevers. Surveillance blood cultures were taken throughout the hospital stay. There were persistent fevers and we needed to consider other sources, such as abdominal source, osteomyelitis and other sources were considered. Surveillance urinalysis grew Enterobacter cloacae and the patient was consequently started on Levofloxacin and given the treatment for seven days. He had continued fevers despite being off the Oxacillin for 96 hours. At this point, he no longer had drug fevers. LENIs of left lower leg were done and they successfully ruled out a deep vein thrombosis or blood clot as another source of fever. With renal function improved, the patient on [6-11] had a bone scan which showed increased uptake in the knee area as expected and increased uptake in the thoracic lumbar area. CT of the chest, abdomen and pelvis showed inflammatory changes in the left paraspinal area in the upper lumbar region. CT and bone scan were concerning for infection. At this point, he was afebrile for a couple of days. We were not comfortable with inflammatory changes in the paraspinal area. Hence, ultrasound was done, which was consistent with hematoma, not abscess. Interventional radiology was contact[Name (NI) ] and they were able to take samples, which were sent off for culture. We were still concerned for abscess versus osteomyelitis versus discitis. Hence, we had the patient go down for magnetic resonance scan of the thoracic and lumbar spine. The [Location (un) 1131] on the magnetic resonance scan of the area that ws called inflammatory changes on CT, was this time read as an abscess. The patient had an abscess in the left paraspinal area that was initially called inflammatory changes and was also noted to have an epidural abscess in the region of T11 to T12. Dr. [Last Name (STitle) 1338] from neurosurgery was consulted and he took the patient to the operating room for incision and drainage. He removed approximately 500 cc of pus and performed a T11 to T12 laminectomy. Cultures taken in the operating room grew out MSSA, hence, the patient was taken off the clindamycin on [6-23]. Allergy consult was obtained and recommended desensitization to Oxacillin which was done on [6-22]. Once on full doses of Oxacillin, the patient's Clindamycin was discontinued. Respiratory failure: The patient was intubated for airway protection on arrival and was left on the ventilator since the patient was being taken to the operating room for patellar wash-out. With development of sepsis, the patient was kept on a ventilator and was placed on low tidal volumes for lung protective strategy, being kept on assist control. Once willing to wean off ventilator, the patient failed. We kept the patient on ventilator while we treated the multiple etiologies that were contributing to his respiratory failure: Volume over load, approximately 33 liters; body habitus; acidemia; sepsis, renal failure. As multiple etiologies improved, we attempted to wean the patient; however, he continued to fail. The patient was noted to like higher amounts of PEEP with this parameter, just as he tolerated decreased amounts of FI02. He would occasionally desaturate with turns, which at the time, were secondary to plugging and responsive to increased suctioning. During the periods of desaturations, the patient was given one hour boluses of increased PEEP and FI02. Once returned to [Location 213], we changed back to previous settings. The patient was weaned off sedation and began waking up but still failing to come off the ventilator. CT surgery was consulted for tracheostomy secondary to failure to wean. Tracheostomy was placed on [6-5]. The patient was eventually weaned from assist control to pressure support, which he tolerated well. The pressure support and PEEP were weaned down as tolerated. Along with the patient's polyneuropathy, he was noted to have severe diaphragmatic weakness, contributing to failure to wean. His recipe was followed on a daily basis and noted to improve to the low 50's by [6-23]. He was tolerating longer and longer trials of pressure support, ultimately was maintained on pressure support and decrease in the pressure support and PEEP. He was able to tolerate pressure support of 15 and PEEPs of 10. Acute renal failure: The patient is a single kidney donor and had developed acute renal failure secondary to hypertension and hypervolemia, developing an ATN picture. FENA was checked and noted to be 3.5, further supporting a diagnosis of ATN. Oliguria noted on day three. Renal was consulted to assist for management and help clarify picture. Their impression was that the patient had developed renal failure, secondary to ATN sepsis. Their recommendation was to start Lasix 60 mg three times a day. This was not started until [5-29]. An ultrasound of the kidney was done to rule out pyelonephritis as a source of which the result was negative. The patient had excellent response to the Lasix and thus was placed on Lasix drip and continued diuresis with negative 1 to 2 liters net per day for several days. He was then placed from Lasix drip to prn Lasix secondary to the development of hyponatremia on [6-1]. The patient had creatinine peak of 8.5 and began to return to normal. He was noted to have spontaneous diuresis on [6-4], secondary to post ATN diuresis. Creatinine and renal function returned to baseline and was at baseline on [6-23]. Total body weakness: Once sedation was off, the patient was noted to have severe weakness. He was unable to move his lower or upper extremities. Toes were down going on examination. Neurology was consulted. EEG was done and was consistent with an ICD polyneuropathy. Neurologic recommended an lumbar puncture to rule out GBS. Lumbar puncture was attempted but failed and eventually was aborted, due to low suspicion. Their impression was that this was all secondary to severe ICD polyneuropathy and not GBS or, in otherwise called [Last Name (un) ]-[Location (un) ] syndrome. The patient had not received any steroids or neuromuscular blockers during this hospital. Noted to have some movement in toes and fingers on [6-20] for the first time. Anemia: The patient's anemia was most likely secondary to anemia of chronic disease. This further worsened, due to phlebotomy and chronic renal disease. The patient was treated several times while in the hospital with repeated blood transfusions, when his hematocrit dropped to less than 21. He was subsequently started on Ferrous Gluconate and 40,000 units of Epo subcutaneous q. week on [2182-6-22] to help facilitate his erythropoiesis and to eliminate it as one of the causes his failure to wean. Hyperglycemia: No previous history of diabetes. The patient was noted to have very elevated blood sugars in this setting which was of concern. [Last Name (un) ] was consulted on day one of admission and their interpretation was that this patient had developed diabetes type I. He was started on an insulin drip with great control of his blood sugars. Eventually, over the course of his hospital stay, he was transitioned to subcutaneous doses of Glargine with regular insulin sliding scale coverage. Rash: The patient was noted to develop drug rash, secondary to Ceftazidime on [5-30]. The Ceftazidime was discontinued and Flagyl was as well. The rash continued and became worse despite discontinuation of Ceftazidime and Flagyl. We then discontinued Oxacillin [6-6] with subsequent improvement of rash and resolution; hence, the patient became allergic to Oxacillin and Ceftazidime. The patient was then desensitized to Oxacillin on [6-22] to [6-23] with no notable rash after those days. Hyponatremia: Secondary to Lasix diuresis and minimal free water replacement. Lasix was stopped and free water deficit was replenished and hyponatremia was resolved. The patient had a second episode of hyponatremia, again secondary to aggressive diuresis with Lasix. Lasix was stopped and free water deficit was replenished and hyponatremia resolved. Alkalemia: The patient was noted to have a transient alkalemia secondary to hyperventilation. Respiratory rate was corrected on the vent settings and alkalemia resolved. No further episodes of alkalemia. Prepatellar bursitis: The patient had been given a steroid injection in the right knee, which consequently became infected. At outside hospital, laboratory studies were notable to grow gram positive cocci. He was placed on Vancomycin, Ceftriaxone and an orthopedic consult was called to evaluate for consideration of debridement. The patient had a bedside wash-out and debridement on the day of admission. The patient was taken on hospital day number two, for wash-out to the operating room. Cultures were taken and sent. Cultures resulted in growing MSSA. He was then started on Oxacillin on day [5-24] and Vancomycin was discontinued. He had wash-out number two on [2182-5-25]. He was subsequently taken for wash-out number three on [5-27] and noted to have frank pus. Wash-out four was done on [6-5] and wash-out number five was done on [6-10]. On [6-10], he was noted to have osteonecrotic bone for osteonecrotic patella; hence, had subsequent patellectomy with extensor reconstruction. Metabolic acidosis: The patient was noted to have ketones in the urine and to be hypoglycemia. Without a past history of diabetes, it was the impression of the team that the patient was indeed showing evidence of diabetes. He was placed on an insulin drip with tight control of blood sugars and chemistries were checked q. 3 hours until gap closed and no longer acidotic. In large part, his metabolic acidosis was secondary to his DKA. He was given aggressive intravenous fluid hydration to correct his dehydration. His urine ketones were followed and chemistries were followed very closely. Insulin drip was titrated for aggressive blood sugar control. His gap closed but he was still very acidotic with non anion gap acidosis. Hence, he was started on bicarbonate per recommendations of renal. Despite bicarbonate supplementation, he continued to be acidemic. Other considerations were very elevated BUN/anemia versus hyperkalemic acidosis secondary to aggressive intravenous fluid hydration with normal saline versus sepsis. Ventilator was used to help correct the acidosis. Once his DKA had resolved, his hyperphosphatemia was treated with Amphojel, with normalization of his uremia/BUN. His metabolic acidosis resolved. Depression: The patient was started on Celexa 20 mg q. h.s., given Ativan for anxiety prn and a psychiatric consult placed with subsequent following throughout the hospital course. Fluids, electrolytes and nutrition: Nutrition was consulted and with their assistance, and continued following throughout his hospitalized stay, we were able to provide him with adequate nutrition. The patient had a percutaneous endoscopic gastrostomy placed and was continued on tube feeds throughout the entire stay. Electrolytes were checked on a daily basis and repleted as necessary. Prophylaxis: The patient was maintained on pneumo boots and then subsequently placed on Lovenox for deep vein thrombosis prophylaxis. Physical therapy and occupational therapy consults were both placed and they followed the patient throughout the remainder of his course. Speech and swallow evaluation was placed, primarily for evaluation for Passy-Muir valve. Once the patient was on lower settings of PEEP, Passy-Muir was supplied to the patient. In the interim, the patient was using a laryngoscopic device to provide vibrations to his vocal cords, to be able to speak. The remainder of this hospital course will be dictated by the next physician. [Name10 (NameIs) ] dictation covers [5-22] to5/30. DR.[Last Name (STitle) ],[First Name3 (LF) ] 12-797 Dictated By:[Last Name (NamePattern1) 49203] MEDQUIST36 D: [2182-7-4] 23:29:25 T: [2182-7-5] 05:30:10 Job#: [Job Number 55872] Admission Date: [2182-6-25] Discharge Date:[2182-7-3] Date of Birth: [2142-12-7] Sex: M Service: MED NOTE: This discharge summary spans the dates beginning [2182-6-25] through [2182-7-4]. This is an addendum. ADDENDUM TO HOSPITAL COURSE: Fevers: The patient continued to spike fevers, despite Oxacillin treatment of his known MSSA bacteremia and lumbar paraspinal abscess. He underwent a transesophageal echocardiogram that was negative for evidence of endocarditis. On [2182-6-28], the patient underwent a magnetic resonance scan of the entire spine to evaluate the known lumbar epidural abscess, as well as to look for any other evidence of infection. The magnetic resonance scan revealed an epidural inflammatory process, extending from the foramen magnum down to the mid thoracic spine. Neurosurgery was reconsulted and the patient was taken to the operating room for another drainage procedure. In the operating room, it was noted that the cervical cord was being compressed by granulation tissue. A portion of this granulation tissue was stripped off. There was no fluid to be drained. It still was not clear if this represented the source of the patient's continued fevers. A sputum culture grew Enterobacter cloaca. The patient was actually treated with a course of Aztreonam; however, the Enterobacter was showing sensitives to Aztreonam. ACT test was performed which revealed evidence of a lingular pneumonia. The patient's antibiotics were, therefore, switched to a course of Levaquin. At the time of dictation, the patient is on day two of ten of his Levaquin course. This CT test also revealed evidence of a loculated effusion on the right pleural space. It was felt that this was unlikely to be infectious in nature; however, if the patient continued to spike high fevers, then he may need a more definitive drainage procedure. Additionally, there was a thought of drug fever as the patient had a prior allergy to Oxacillin, for which he was desensitized and he had a peripheral eosinophilia and a mild rash. At the time of this dictation it is not entirely clear what the source of his recurrent fevers were; however, his fever curve had been titrating down. Paraplegia: Initially it was thought that the patient's weakness, inability to wean from the vent was due to IC polymyopathy; however, when the epidural granulation tissue of the cervical spine was revealed by the magnetic resonance scan, it was felt that there was likely an epidural abscess secondary to his MSSA infection and that the development of granulation tissue caused compression of the cervical cord, as well as the possibility of septic thrombophlebitis, causing cord infarcts. As mentioned previously, after neurosurgery and neurology evaluation, the patient was taken to the operating room for stripping of this granulation tissue and relief of the pressure on the cord. Physical therapy and occupational therapy worked closely with the patient and he will need long term spinal cord rehabilitation in order to achieve significant improvement. Respiratory failure: As mentioned above, it was felt that diaphragmatic weakness, secondary to cervical cord lesion was the likely etiology for his inability to wean off the vent. The patient is status post a tracheostomy and was maintained on pressure support settings and will likely be vent dependent until significant cervical cord function is returned. Diabetes: The patient's sugars remained in excellent range on his twice a day Lentis dosing. The remainder of this discharge summary, including the patient's diagnoses, discharge medications will be dictated as a part of an addendum to this summary. [Name6 (MD) ] [Name8 (MD) ], [MD Number(1) 2019] Dictated By:[Last Name (NamePattern1) 12327] MEDQUIST36 D: [2182-7-3] 22:28:38 T: [2182-7-4] 04:31:23 Job#: [Job Number 55873] Admission Date: [2182-5-22] Discharge Date:[2182-7-9] Date of Birth: [2142-12-7] Sex: M Service: MED ADDENDUM: HOSPITAL COURSE: The remainder of the [Hospital 228] hospital stay was uneventful. He had a speech and swallow evaluation which cleared him to tolerate all p.o. which he did without problem. Additionally, he remained afebrile except for an occasional low grade temperature that was not pursued. His culture data remained negative. Therefore, he was discharged to rehabilitation facility. DISCHARGE DIAGNOSES: Diabetic ketoacidosis. New onset diabetes mellitus. Methicillin sensitive Staphylococcus aureus. Bacteremia. Methicillin sensitive Staphylococcus aureus left septic knee joint. Lumbar paraspinal epidural abscess, cervical epidural abscess. Respiratory failure. Paraplegia. Pneumonia. SURGICAL PROCEDURES: Percutaneous J tube. Bronchoscopy. Lumbar puncture. Tracheostomy. Open debridement of the right knee. Thoracentesis. Serial incision and drainage washouts of the right knee. C4 to C7 laminectomies and stripping of the cervical epidural granulation tissue, drainage of the lumbar paraspinal abscess and T11 to T12 laminectomies. MEDICATIONS ON DISCHARGE: 1. Lansoprazole 30 mg NG once daily. 2. Celexa 20 mg NG once daily. 3. Multivitamin one once daily. 4. Vitamin C 500 mg twice a day. 5. Zinc 220 once daily. 6. Ferrous Gluconate 300 mg once daily. 7. Albuterol meter dose inhaler two to four puffs q4hours p.r.n. wheeze. 8. Enoxaparin 40 mg subcutaneously once daily. 9. Epogen 10,000 units one injection three times a week q.Tuesday, Thursday and Saturday. 10. Ambien 5 mg tablet, one to two q.h.s. p.r.n. insomnia. 11. Fentanyl patch 75 mcg per hour q72hours. 12. Oxycodone 5 mg one to two tablets q3hours as needed for breakthrough pain. 13. Levaquin 500 mg tablet one once daily times four days. 14. Oxacillin two grams intravenously q4hours times seven and one half weeks. 15. Insulin-Glargine subcutaneously 50 units twice a day with a regular insulin sliding scale. FOLLOW UP: Follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9404] of infectious disease on [2182-8-5]. Follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] of orthopedics on [2182-7-26]. Follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on [2182-8-21]. Follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1338] of neurosurgery. He will need to call to schedule this appointment. Follow-up magnetic resonance imaging of his spine on [2182-7-31]. [Name6 (MD) ] [Name8 (MD) ], [MD Number(1) 2019] Dictated By:[Last Name (NamePattern1) 12327] MEDQUIST36 D: [2182-7-7] 11:25:50 T: [2182-7-7] 12:19:51 Job#: [Job Number 55874] Name: [Known lastname 10483], [Known firstname ] Unit No: [Numeric Identifier 10484] Admission Date: Discharge Date: [2182-7-9] Date of Birth: [2142-12-7] Sex: M Service: MED This is an addendum for the remainder of the hospital course. Patient spiked a recurrent fever to 101. Initially a diagnostic thoracentesis of the right loculated effusion was planned. However, after evaluation by ultrasound the fluid was an insignificant amount and nothing amenable to thoracentesis. It was felt that this was an unlikely cause of his fever, and therefore no further procedures were pursued. Additionally, patient developed an increased skin rash, that with his history of oxacillin allergy as well as peripheral eosinophilia. It was felt that the fever could be secondary to a drug allergy. Therefore, patient's oxacillin was changed to vancomycin one gram q. 12 hours, and this medication will be continued for another seven-and-a-half weeks as per the original plan. Thus, patient was discharged to [Hospital 4418] [Hospital ] Rehab on [2182-7-9]. The patient's discharge diagnoses and discharge medications are the same as the prior discharge summary with the exception of oxacillin for which vancomycin will be substituted one gram q. 12 hours times seven-and-a-half weeks. [Name6 (MD) ] [Last Name (NamePattern4) ], MD [MD Number(1) 7079] Dictated By:[Last Name (NamePattern1) 8833] MEDQUIST36 D: [2182-7-9] 15:17:44 T: [2182-7-9] 15:36:45 Job#: [Job Number 10485]	[ "507.0", "038.11", "518.0", "995.92", "599.0", "711.06", "276.2", "276.3", "250.11" ]	icd9cm	[ [ [] ] ]	[ "83.03", "03.4", "96.6", "34.91", "96.04", "80.86", "44.32", "88.72", "31.1", "96.72" ]	icd9pcs	[ [ [] ] ]							2921, 3048	23853, 24503				24529, 25404		23451, 23831																									25416, 27849					3352, 4823																			164, 2752																	2775, 2904	3065, 3329
78,364	166,718	11101	Discharge summary	report	Admission Date: [2141-3-9] Discharge Date: [2141-3-14] Date of Birth: [2088-11-1] Sex: M Service: MEDICINE Allergies: Trileptal Attending:[First Name3 (LF) 425] Chief Complaint: low back pain Major Surgical or Invasive Procedure: Ventricular Tachycardia Ablation. History of Present Illness: HISTORY OF PRESENTING ILLNESS: 52 M with hx chronic low back pain s/p surgery [12-7] who presented to [Hospital 47] hospital ED with worsened back pain in the setting of a recent fall. He has been on narcotics with some estrangement from his PCP and went to the ED seeking pain relief . He also noted that he had woken up with mild neck pain and proximal arm numbness accompanied by mild SOB, palpitations and pleuritic chest pressure all of which he associated with anxiety. He denies any illicit drugs, caffeine use. On arrival to the [Location (un) 47] ED he was noted to be tachycardic with HR in 180s and he was found to be in wide complex tachycardia on EKG which was initially thought to be an SVT and he received several doses of adenosine which he was sensitive to, but didn't break, going into sinus, then bigeminy then back into VT. He subsequently received 100mg lidocaine and returned to sinus rythm and he has been in sinus since. . Of note, he underwent cardiac catheterization within the past year for exertional chest discomfort and a reportedly abnormal stress test. . EKG: Single PVC which was different in morphology to his PVC. Left axis, Left bundle, positive in inferior leads and inferior laterally-briefly responsive to adenosine. . Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or presyncope. . In the ED, HR 102 on lidocaine gtt, vitals otherwise wnl, chest pain free.On arrival to the floor, [3-8] neck/chest pain with negative EKG, severe back pain with dilaudid given and lidocaine gtt continued. Past Medical History: Hypertension Depression: major depressive episode with hosptialization in [8-7]. Anxiety Chronic Back pain s/p Laminectomy Social History: SOCIAL HISTORY -Tobacco history: 30ppy hx -ETOH:distant -Illicit drugs:none Lives with friends in [Name (NI) 47], former truck driver. Going through stressful divorce. . Family History: FAMILY HISTORY: Maternal hx HTN Physical Exam: VS: T=97.5 BP=124/77 HR=94 RR=14 O2 sat= 98% RA GEN: A0X3 CVS: RRR, no MRG, S1 S2 clear Lung: CTA-B Abd: +bs, soft, nt, nd TTP in right lower back Ext:no femoral bruit good peripheral pulses Pertinent Results: [2141-3-9] 08:40PM GLUCOSE-95 UREA N-15 CREAT-1.0 SODIUM-140 POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-24 ANION GAP-13 [2141-3-9] 08:40PM CK(CPK)-37* [2141-3-9] 08:40PM cTropnT-0.03* [2141-3-9] 08:40PM CK-MB-NotDone [2141-3-9] 08:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2141-3-9] 08:40PM WBC-13.9* RBC-4.38* HGB-13.6* HCT-40.7 MCV-93 MCH-30.9 MCHC-33.3 RDW-15.5 [2141-3-9] 08:40PM NEUTS-70.3* LYMPHS-20.3 MONOS-6.5 EOS-2.2 BASOS-0.7 [2141-3-9] 08:40PM PLT COUNT-252 [2141-3-9] 08:40PM PT-11.7 PTT-25.7 INR(PT)-1.0 . [2141-3-9] FINDINGS: The lungs are clear without consolidation or edema. The mediastinum is unremarkable. The cardiac silhouette is within normal limits for size. No effusion or pneumothorax is identified. The visualized osseous structures are unremarkable. IMPRESSION: No acute pulmonary process. . Cardiac MRI [2141-3-10]: Impression: 1. Mildly increased left ventricular cavity size with mild global left ventricular systolic dyfunction. The LVEF was mildly depressed at 49%. The effective forward LVEF was moderately depressed at 36%. There is CMR evidence of prior myocardial scarring/fibrosis in the right ventricular insertion sites and lateral wall as detailed above in a non-coronary pattern. 2. Normal right ventricular cavity size and systolic function. The RVEF was normal at 47%. No CMR evidence of right ventricular dysplasia however right ventricular fatty infiltration cannot be excluded. 3. Moderate mitral regurgitation with rheumatic deformity of both mitral valve leaflets and the subvalvular apparatus. Mild pulmonic regurgitation. Mild tricuspid regurgitation. 4. The indexed diameters of the ascending and descending thoracic aorta were normal. The main pulmonary artery diameter index was normal. 5. Biatrial enlargement. . Labs at discharge: [2141-3-14] 05:20AM BLOOD WBC-13.9* RBC-4.57* Hgb-13.6* Hct-41.8 MCV-92 MCH-29.8 MCHC-32.6 RDW-15.0 Plt Ct-271 [2141-3-14] 05:20AM BLOOD Neuts-69.6 Lymphs-21.1 Monos-6.5 Eos-1.9 Baso-0.8 [2141-3-14] 05:20AM BLOOD Glucose-91 UreaN-20 Creat-1.1 Na-141 K-4.5 Cl-103 HCO3-28 AnGap-15 Brief Hospital Course: #1 Ventricular tachycardia: Seen in ED in [Location (un) 1110] while pt being evaluated for low back pain and transferred here for management. Pt states he has had symptoms in the past but has not been evaluated. Was on Lidocaine drip before ablation. S/P successful RVOT ablation [3-13]. Cardiac MRI suggests related to old scar tissue. No evidence of ischemia as trigger. No further sifnificant VT on tele after ablation. Metoprolol was increased for rate control. Aspirin was increased to 325 mg per protocol after ablation. Pt did not complain of any chest soreness after ablation. right and left groin sites unremarkable after procedure. Pt instructed on activity restrictions before dischage. . #2 Depression/Anxiety: major depressive episode with hosptialization in [8-7]. Seen by SW yesterday who felt that although pt had multiple stressful issues, was coping well and appropriately following outpatient psychiatrist. Celexa, Klonopin and Trazadone was continued per outpatient regimen. . #3 Low Back Pain: Primary complaint on admission and continued to be a major complaint during hospital stay. Bedrest was thought to exacerbate chronic LBP and pt was initially treated to dilaudid IV and transitioned to oxycodone PO q 4hours. Pt took 2 tablets every 4 hours for a few days until discharge. On day of discharge, outpatient pain clinic physician, [Last Name (NamePattern4) ]. [First Name (STitle) ], was contact[Name (NI) ] and related history of narcotic seeking behavior that included multiple trips to ED with narcotic request. Dr. [First Name (STitle) ] had treated pt with steroid injections in the past and recommended heat/ice and moderate activity for home management of pain. Pt was asking for oxycodone prescription at discharge stating that Pain clinic did not adequately treat his pain. CCU team decided not to prescribe further narcotics given that bedrest was now complete and pt was able to ambulate independently. It was strongly recommended to pt that he follow up this week with Dr. [First Name (STitle) ] and PCP. . #4 Leukocytosis: ? stress response. No fever, exam non-focal. Stable at discharge with no evidence of infection. . #5 Hypertension: Well oontrolled on increased Metoprolol, clonidine was held and not restarted at discharge. Medications on Admission: Klonopin 1mg TID trazadone 200mg QHS metoprolol 25 [Hospital1 ] celexa 40mg qd neurontin 900 TID flexaril 60 mg daily, ? correct dose clonidine 0.2 mg daily Aspirin 81 mg daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO three times a day. 3. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:2 6. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). Disp:270 Capsule(s) Refills:2 8. Cyclobenzaprine Oral Discharge Disposition: Home Discharge Diagnosis: Ventricular Tachycardia Chronic Low back pain s/p laminectomy Hypertension Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You had ventricular tachycardia that was caused by scar on your heart muscle seen on the MRI. We performed an ablation that should prevent this arrythhmia in the future. WE increased your metoprolol to also prevent any arrhythmias. WE treated your chronic low back pain by increasing your neurontin. You need to make an appt with Dr. [First Name (STitle) ] at the pain clinic to continue treatment for low back pain. Medication changes: 1. Increase your Metroprolol to 75 mg twice daily to prevent the fast heart rhythm. 2. Increase aspirin to 325 mg daily 3. Increase Neurontin to 900 mg to treat your low back pain. Followup Instructions: Pain clinic: [First Name8 (NamePattern2) ] [Doctor Last Name ]: Phone: ([Telephone/Fax (1) 35817] Date/Time: please make an appt to be seen this week. . Completed by:[2141-3-27]	[ "300.4", "724.2", "401.9", "427.1", "288.60", "338.29" ]	icd9cm	[ [ [] ] ]	[ "37.34", "37.26", "37.27" ]	icd9pcs	[ [ [] ] ]	7916, 7922	4775, 7080	282, 318	8041, 8041	2579, 4440	8835, 9031	2335, 2352		7312, 7893		7943, 8020		7106, 7289				8189, 8610													2367, 2560																						8630, 8812				229, 244			4459, 4752				346, 1959											8056, 8165						1981, 2111	2127, 2303
17,451	132,652	1308+1309	Discharge summary	report+report	Admission Date: [2162-3-15] Discharge Date: [2162-3-21] Date of Birth: [2122-5-16] Sex: M Service: ADMISSION DIAGNOSIS: 1. Drug abuse. 2. Depression. DISCHARGE DIAGNOSIS: 1. Polysubstance abuse, drug intoxication, cocaine abuse, opiate abuse. 2. Depression. 3. Bipolar. 4. Drug overdose. HISTORY OF THE PRESENT ILLNESS: The patient is a 39-year-old male with a past medical history of suicidality, polysubstance abuse, depression, who presents with a drug overdose. The patient had originally taken himself to [Hospital3 8063] on the day of admission for detoxification. The patient has a known history of cocaine abuse, starting cocaine at age 17. The patient was found on the day of admission by the staff to have spastic movements in chair. He had told the staff that he had taken large amounts of cocaine and unable to control himself. The patient was given Thorazine 25, Klonopin and Ativan and transferred to [Hospital1 18] for agitation. In the ambulance, the respiratory rate was 24, pulse 94, blood pressure 148/78. In the Emergency Room, the patient was given Ativan 12 mg total, Versed 2 mg, Benadryl 25 mg IV. The patient was intubated secondary to mental status change. In the Emergency Room, the patient was waxing and [Doctor Last Name 688] between acute violent and agitated moods and somnolence. Therefore, he was intubated. In the ED, the vital signs revealed a temperature of 99.4, pulse 118, blood pressure 161/82, respiratory rate 16, pulse ox 100% on 2 liters before intubation. PAST MEDICAL HISTORY: 1. Suicidality times two. 2. Polysubstance abuse. 3. Depression. 4. Reflux. 5. Question of bipolar. 6. Question of asthma. 7. Question of narcolepsy. ALLERGIES: The patient has no known drug allergies. ADMISSION MEDICATIONS: 1. Thorazine 25 q.a.m., 50 q.p.m. 2. Klonopin. 3. Ativan. 4. Depakote. 5. Wellbutrin. 6. Protonix. 7. Vioxx. SOCIAL HISTORY: The patient is on disability secondary to a construction accident. No tobacco or alcohol use. No history of IV drugs, per family. Positive cocaine use since age 17. Contact: Mother, [Telephone/Fax (1) 8064]. PCP: .................... . PHYSICAL EXAMINATION ON ADMISSION: Vital signs: 120/72, heart rate 95, pulse ox 100%, 12, FI02 50%, 700 by 12 AC. General: Intubated, sedated, restrained. HEENT: Anicteric. OP intubated. Pupils myotic, reactive. Cardiovascular: Regular rate and rhythm. Normal S1, S2. Lungs: Clear bilaterally. Abdomen: Soft, nontender. Extremities: No cyanosis or edema. Neurologic: Intubated, sedated. Pupils 1.5 mm to 1 mm axis to peripheral. LABORATORY DATA: White blood cell count 17.2, hematocrit 39.6, platelets 470,000, platelets 71,000, lymphs 18, M 5, E 0.4, basophils 0.5. Electrolytes: Sodium 142, K 4.2, chloride 103, bicarbonate 27, BUN 21, creatinine 1.1, potassium 141, CK 1368, MB 16, index 2, troponin less than 0.3. ABGs: 7.31, 59, 153, status post intubation. EKG: Tachy at 108, normal axis, slightly prolonged QT, early PR wave progression, no acute ST changes. CT of the head: No acute process. U/A: Yellow, clear, poly negative, glucose trace, ketones negative. Serum tox: Negative. Urine tox: Positive for benzos, barbiturates, opiates, and cocaine. ASSESSMENT/PLAN: This is a 39-year-old male with a past medical history of polysubstance abuse with suicidal ideation who presents with acute ingestion, one acute ingestion. The patient presents with polysubstance abuse. The patient was intubated for airway protection, extubated on [2162-3-17]. The patient was initially placed on propofol and Ativan. The patient's Ativan was weaned and he was given Haldol for acute p.r.n. agitation. Dictated By:[Last Name (NamePattern1) 201] MEDQUIST36 D: [2162-3-21] 08:57 T: [2162-3-21] 09:34 JOB#: [Job Number 8065] Admission Date: [2162-3-15] Discharge Date: [2162-3-21] Date of Birth: [2122-5-16] Sex: M Service: MICU HOSPITAL COURSE: 2. Respiratory - The patient intubated for mental status change and extubated on [2162-3-20], without any complications. The patient's chest x-ray initially read as possible aspiration. The patient initially placed on Levofloxacin and Flagyl. Subsequent x-ray showed improvement and resolution of possible infiltrate. The patient had several x-rays in house to evaluate question of large mediastinum. Radiologist noted likely secondary to rotation. 3. Cardiac - The patient presented with slightly prolonged Q-T on electrocardiogram. The prolonged Q-T resolved during hospital course. Of note, the patient had echocardiogram to evaluate for endocarditis given the onset of bacteremia (one set of blood cultures positive for alpha Streptococcus). Echocardiogram showed normal systolic function, left atrial mildly dilated, left ventricular wall thickness, cavity size and systolic function were normal. Aortic root was mildly dilated. 4. Renal - The patient with elevated CKs on presentation. The patient's CKs trending downward. The patient initially provided with bicarbonate to alkalinize urine. The patient's blood urea nitrogen and creatinine remained stable with hydration. 5. Psychiatric - The patient evaluated by psychiatry in house. The patient was started on Thorazine prior to discharge. The patient's Wellbutrin was held. The patient discharged on CIWA Ativan and Haldol p.r.n. for acute agitation and Thorazine. 6. Infectious disease - The patient initially started on Levofloxacin and Flagyl for question of aspiration on x-ray. Of note, sputum cultures were sent. Sensitivities pending at the time of discharge. Initial set of blood cultures, one anaerobic and one aerobic bottle positive for alpha Streptococcus. Subsequent blood cultures were negative times two. We discontinued Levofloxacin on discharge. DISPOSITION: To [Hospital1 ]. MEDICATIONS ON DISCHARGE: 1. Albuterol nebulizers one nebulizer q6hours p.r.n. 2. Lorazepam 2 mg intravenously q.hours p.r.n. CIWA scale greater than ten. 3. Haldol 5 mg intravenously q3-4hours severe agitation. 4. Multivitamin one capsule p.o. once daily. 5. Chlorpromazine Hydrochloride 50 mg p.o. q.h.s., 25 mg p.o. q.a.m. 6. Tylenol 500 mg p.o. q4-6hours p.r.n. 7. Divalproex Sodium 500 mg p.o. twice a day. 8. Ibuprofen 800 mg p.o. q8hours p.r.n. 9. Fioricet one tablet p.o. q6hours. DISCHARGE DIAGNOSES: 1. Drug intoxication. 2. Drug overdose. 3. Mental status change. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 288], M.D. [MD Number(1) 8066] Dictated By:[Last Name (NamePattern1) 201] MEDQUIST36 D: [2162-3-21] 12:37 T: [2162-3-21] 14:05 JOB#: [Job Number 8067]	[ "518.81", "E854.3", "728.89", "790.7", "970.8", "305.50", "507.0", "305.60", "292.81" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]								6447, 6792			206, 1564	5953, 6426		4041, 5927					1821, 1938																										152, 185																											2238, 4024								1586, 1798	1955, 2223
52,453	106,967	3768	Discharge summary	report	Admission Date: [2173-10-5] Discharge Date: [2173-10-10] Date of Birth: [2120-3-3] Sex: F Service: MEDICINE Allergies: Lisinopril / Oxycodone Attending:[First Name3 (LF) 1990] Chief Complaint: Fevers, chills, sweats, ?sepsis Major Surgical or Invasive Procedure: None History of Present Illness: 53 y/o F with antiphospholipid syndrome on warfarin and ESRD [1-12] lupus nephritis on HD since [2167] now s/p renal txp in [2173-2-8] on immunosuppression, referred to ED from primary care office where she presented with fevers and chills x three weeks. She also told her providers in the primary care clinic that she has been vomiting and having abdominal pain and urinary frequency. She had reportedly not been eating well, but denied dysuria. In PCP's office today, she was febrile to 103.2 orally, with HR of 116 and BP of 115/80. She was described as lethargic and sleepy for most of the visit, but easily aroused. Exam was notable for vital signs as above, cool extremities and tenderness over LLQ and RLQ over her transplanted kidney. She was sent to the ED to evaluate for an intra-abdominal, genitourinary, or respiratory source of SIRS/sepsis. In the ED, triage vital signs were 100.5, 116, 125/74, 18, 97% RA. Exam notable for rigoring, tachycardia, 2/6 systolic murmur, +RLQ TTP without rebound tenderness or guarding. She was reportedly AAO x2. Labs notable for INR 2.9, lactate 1.1. Non-contrast CT abd/pelvis showed a malpositioned foley catheter but no explanation for fevers. There was no perinephric stranding or abscess. Ultrasound of the transplanted kidney showed increased resistive indices but no hydronephrosis or perinephric fluid collections. The patient was given two liters of IVF, and one amp of D50 for hypoglycemia. She was given 1g each of vancomycin, cefepime, and acetaminophen. A third liter of NS was started prior to transfer to the MICU. Transplant surgery was consulted, and did not feel she needed urgent surgical intervention. Transfer VS per verbal report were temp 102, HR 120, RR 19, 99% RA, 96/59. Upon arrival to the MICU, the patient had a low-grade fever to 100.2. She says she is feeling much better than earlier, and her shaking and chills have stopped. She denies ever having had a cough or dyspnea. Denies urinary frequency, polyuria, or difficulty voiding. Denies abdominal pain, nausea, vomiting, diarrhea, or constipation. She was started on D5NS at 120 cc/hr. Past Medical History: -LUPUS -ANTIPHOSPHOLIPID SYNDROME -ESRD [1-12] LUPUS NEPHRITIS s/p DCD txp [2-17] (recent creat 2.3) (Postop course was complicated by SVC syndrome requiring reintubation MRV showed bilateral brachecephalic vein occlusion on [2173-2-19]. She underwent venoplasty and stent placement of the Right subclavian vein, brachiocephalic and SVC. Post procedure she was started on heparin gtts and transitioned to Coumadin) -THYROID NODULE [2159] -ANGIOEDEMA [2172-10-21] -HYPERTENSION -HYPERCHOLESTEROLEMIA Social History: Born in [Country 2045]. She was widowed in 6/[2169]. She lives alone in [Location (un) ], with 1 son nearby. [Name2 (NI) ] other 3 children are still in [Country 2045]. She denies any tobacco, ethanol or illicit drug use. Family History: Significant for a maternal uncle with hypertension; otherwise denies any family history of heart disease, cancer or diabetes. Mother died of unclear causes when patient was 7 yo. Father died of unclear causes in [2152]. Physical Exam: VS: Temp:100.2 BP:116/51 HR:103 (regular) RR:17 O2sat:100% RA GEN: pleasant, comfortable, NAD. Sitting up in bed. HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd RESP: CTA b/l with good air movement throughout. No wheezes or crackles. CV: RR, S1 and S2 wnl, no m/r/g ABD: Well-healed surgical scar over RLQ. Softly distended, +NABS x4, nt, no masses or hepatosplenomegaly. No TTP over LLQ, RLQ, or elsewhere. No rebound tenderness or guarding. EXT: no c/c/e SKIN: + hypopigmented patch over right shoulder extending medially and inferiorly to mid-back, with interspersed hyperpigmented papules (reportedly chronic birthmark). no rashes/no jaundice/no splinters NEURO: AAOx3. CN II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated RECTAL: Deferred Pertinent Results: Initial Labs: [2173-10-5] 10:48AM WBC-5.3# RBC-3.71* HGB-11.1* HCT-32.5* MCV-88 MCH-29.9 MCHC-34.1 RDW-15.6* [2173-10-5] 10:48AM NEUTS-81* BANDS-4 LYMPHS-5* MONOS-8 EOS-0 BASOS-1 ATYPS-1* METAS-0 MYELOS-0 [2173-10-5] 10:48AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL [2173-10-5] 10:48AM PLT SMR-NORMAL PLT COUNT-195 [2173-10-5] 10:48AM PT-29.0* PTT-31.7 INR(PT)-2.9* [2173-10-5] 10:48AM tacroFK-3.9* [2173-10-5] 10:48AM ALBUMIN-3.9 [2173-10-5] 10:48AM LIPASE-23 [2173-10-5] 10:48AM ALT(SGPT)-13 AST(SGOT)-32 LD(LDH)-338* ALK PHOS-67 AMYLASE-146* TOT BILI-0.6 [2173-10-5] 10:48AM GLUCOSE-38* UREA N-27* CREAT-2.5* SODIUM-133 POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-22 ANION GAP-18 [2173-10-5] 11:49AM LACTATE-1.1 [2173-10-5] 05:20PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.012 [2173-10-5] 05:20PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2173-10-6] 12:00PM BLOOD WBC-3.3* RBC-3.01* Hgb-9.0* Hct-26.7* MCV-89 MCH-30.0 MCHC-33.9 RDW-15.7* Plt Ct-131* [2173-10-7] 04:55AM BLOOD WBC-2.8* RBC-3.01* Hgb-9.0* Hct-26.3* MCV-88 MCH-30.1 MCHC-34.4 RDW-15.7* Plt Ct-146* [2173-10-8] 05:55AM BLOOD WBC-2.5* RBC-3.16* Hgb-9.5* Hct-27.7* MCV-88 MCH-30.1 MCHC-34.3 RDW-15.7* Plt Ct-170 [2173-10-9] 07:05AM BLOOD WBC-1.9* RBC-3.16* Hgb-9.5* Hct-27.6* MCV-87 MCH-30.0 MCHC-34.4 RDW-15.8* Plt Ct-198 [2173-10-10] 06:00AM BLOOD WBC-1.6* RBC-3.30* Hgb-9.8* Hct-28.8* MCV-87 MCH-29.8 MCHC-34.0 RDW-15.5 Plt Ct-199 Microbiology: blood cx: [10-5] Blood Culture, Routine (Preliminary): e coli GRAM NEGATIVE ROD(S). PRELIMINARY SENSITIVITY. SENSITIVITIES: MIC expressed in MCG/ML _____________________________________________________ GRAM NEGATIVE ROD(S) \| AMIKACIN-------------- S AMPICILLIN------------ S AMPICILLIN/SULBACTAM-- S CEFEPIME-------------- S CEFTAZIDIME----------- S CEFTRIAXONE----------- S CIPROFLOXACIN--------- S GENTAMICIN------------ S MEROPENEM------------- S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ S stool toxin: [10-5] c diff positive Imaging: CXR: [10-5] No acute pulmonary process. Stable chest x-ray exam Renal U/S: [10-5] No evidence of hydronephrosis or perinephric fluid collection. Increased resistive indices since prior exam in [Month (only) 216], correlate with renal function. CT abdoman/ pelvis: [10-5] 1. No acute findings in the abdomen or pelvis to explain patient's fevers, within the limits of this non-contrast enhanced technique. 2. Tip of the Foley catheter within the distal ureter of the transplanted kidney causing mild hydroureteronephrosis. No perinephric collections or masses. No evidence for abscess. 3. Fecal loading in the rectum without bowel obstruction Brief Hospital Course: Please note that pt left against medical advice . . 53 y/o immunosuppressed female s/p renal transplant in [Month (only) 958] [2172], presenting from PCP's office with three weeks of chills, now with documented fevers tachycardia, borderline hypotension, and hypoglycemia. . 1. Sepsis secondary to ecoli bacteremia: On presentation, meet SIRS criteria with fevers, tachycardia and mild bandemia from suspected infectious source especially given immunosuppression. Pancultured in the emergency department and placed on empiric broad-spectrum antibiotics with vancomycin and cefepime. To evaluate for etiology, CXR and CT scan of abdomen was performed with no apparent abnormality besides stool impaction in the rectum. Urinalysis did have minimal blood and white blood cells, but culture returned negative. Stool cx returned positive for cdiff and patient was started on flagyl. Blood cx from [10-5] grew pansensitive ecoli and antibiotics were subsequently narrowed to ciprofloxacin (and flagyl). The most likely source of ecoli bacteremia was thought to be translocation from gut in setting of mild colitis. The patient was transiently hypotensive in the emergency department, but responded to fluid boluses. With antibiotic therapy, she defervesced, tachycardia resolved, and subjective complaints of chills improved. Surveillance blood cx from [10-6] were negative for 48 hrs, pt was continued on cipro/flagyl but developed leukopenia and flagyl was discontinued (bc can contribute to leukopenia) and changed to PO vancomycin. Authorization for PO vanco could not be obtained over the weekend and pt decided to leave against medical advice in lieu of waiting for vanco authorization. Pt was advised to continue vanco for 2 weeks more after completing 2 week course of cipro. She has outpt f/u in transplant clinic to have WBC count checked (in addition to INR and tacro levels, as below). At time of discharge, pt was abebrile >72 hrs, had no diarrhea, no abd pain, no N/V. Of note, mycophenolate mofetil was discontinued as well prior to discharge given leukopenia. Bactrim and valcyte, though also can cause leukopenia, were continued as pt has been on these for a long time without complications. Most likely leukopenia was due to recent initiation of flagyl, and should improve on cipro/vanco regimen. MMF was held until follow up as this may have been contributing to her neutropenia. . 2. ESRD s/p transplant: History of lupus nephritis s/p renal transplant on cellcept, tacrolimus and prednisone. Baseline creatinine is in the 1s, but has been slowly increasing since [Month (only) 205] and has been as high as 2.7 in the recent past. Etiology of developping renal insufficiency is unclear: CT scan with no evidence of obstruction, urinalysis without active sediment to suggest recurrent lupus nephritis. The patient may have chronic volume depletion, she is on bactrim for PCP [Name9 (PRE) ] which may artifactually increase creatinine. Also, it is unclear whether she is compliant with her immunosuppressants at home. A renal biopsy may be pursued as an outpatient. During hospitalization, renal function was trended daily and patient continued on immunosuppressants with bactrim for PCP [Name Initial (PRE) ]. Daily tacrolimus levels were also followed with level adjusted as needed. Goal level [7-20], tacro level 6.4 at discharge, per renal consult continued 2mg [Hospital1 ] dosing of tacrolimus. Cellcept was discontinued prior to discharge given leukopenia (as above). Pt has f/u in renal transplant clinic to have tacro levels rechecked and to check WBC count, will modulate immunosuppression regimen based on those results. . 3. Antiphospholipid syndrome: on longterm anticoagulation with warfarin for history of APLS (Anticardiolipin Ab's showing elevated IgG and normal IgM in [3-17] and [7-17]) with multiple prior thrombotic occlusions of dialysis fistula. PT/INR followed daily with warfarin supratherapeutic on [10-6] to 4.7. INR at 2.9 to 2.1 on discharge (goal [1-13]). Coumadin was restarted at 1mg daily with f/u day after discharge to check INR levels and to adjust coumadin accordingly. . 4. SLE: Outpatient rheumatology notes indicate patient diagnosed in [2165] and initially seen at [Hospital1 112] lupus clinic. Last [Hospital1 18] rheumatology clinic visit [1-20], documenting history of lupus nephritis and AVN of ankles with last documented [Doctor First Name ] positive 1:160 in [2169], though dsDNA Ab's have been negative when checked since [2171]. No findings on history or physical consistent with lupus flair. . 5. Hypertension: Pt has history of hypertension treated with metoprolol only, with past systolic blood pressure measurements documented in the 110-140 range, per OMR. Documented BP's in ED generally in low 100s, with IVF infusion. Given systemic HTN, home metoprolol initially held but restarted prior to discharge. . 6. Hyperlipidemia: Last lipid panel in [2172-9-10], with TC 144, HDL 39, LDL 81, TG 120. Not currently receiving treatment, but was taking simvastatin through [2172-3-11]. . 7. Hyponatremia: Mild, without alterations in mental status. Likely poor PO intake over past days-weeks would suggest hypovolemic hyponatremia. Improved following IVF bolus in emergency department. . 8. Osteoporosis: Last bone densitometry scan in [2173-4-10], consistent with osteoporosis, in setting of chronic glucocorticoid therapy and hyperparathyroidism. Medications on Admission: 1. Mycophenolate Mofetil 1000 mg PO BID 2. Acetaminophen 650 mg PO/NG Q6H:PRN fever, pain 3. PredniSONE 5 mg PO/NG DAILY 4. CefePIME 1 g IV Q24H 5. Sulfameth/Trimethoprim SS 1 TAB PO/NG DAILY 6. Cinacalcet 30 mg PO DAILY 7. Tacrolimus 2 mg PO Q12H 8. Famotidine 20 mg PO/NG Q24H 9. ValGANCIclovir 450 mg PO DAILY 10. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 11. Warfarin 1 mg PO/NG DAILY16 Discharge Medications: 1. Outpatient Lab Work Please have your INR checked at [Hospital3 ] ([Company 191]) on Monday, [10-11]. Please fax to [Telephone/Fax (1) 3534]. 2. Outpatient Lab Work Please have your tacrolimus level, CBC, and INR checked at renal transplant clinic on [10-18]. 3. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 5. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 8. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: please have your INR checked on [10-11]. 9. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 10. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 12. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 11 days. Disp:11 Tablet(s) Refills:0 13. vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 25 days. Disp:100 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: E coli bacteremia C diff . Secondary: SLE Antiphospholipid antibody s/p renal transplant Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You are leaving the hospital against medical advice. . You were admitted to [Hospital1 18] with fevers and chills. You were found to have bacteria from your blood (E. coli) which likely came from your bowel tract. You have an infection in your bowels called C diff which can be contracted while on immunosuppression and during hospitalizations. You are being treated for both infections with antibiotics. Your kidney function improved with fluids. Your INR level has been higher than optimal because your antibiotics can interfere with coumadin. We held your coumadin, but restarted it before your discharge, INR should be closely monitored when you leave the hospital. Please follow up with the coumadin clinic tomorrow. . We have made the following changes to your medications: Decrease your tacrolimus to 2mg twice a day Take cipro for 11 more days (last day = [10-20]) Take vancomycin for 25 more days (last day = [11-3]) Stop taking mycophenolate mofetil (cellcept) until you follow up with the kidney transplant doctors Continue to take coumadin 1mg daily, but have your INR checked at [Hospital 191] [Hospital3 ] on [10-11] to make sure it is therapeutic Followup Instructions: The following appointments have been scheduled for you: . Please have your INR checked at [Hospital 191] [Hospital3 ] on Monday, [10-11]. . Department: [Hospital3 249] When: MONDAY [2173-10-18] at 9:30 AM With: [Company 191] POST [Hospital 894] CLINIC [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: WEST [Hospital 2002] CLINIC When: MONDAY [2173-10-18] at 1 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2540], RN [Telephone/Fax (1) 721] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Please follow up with the kidney transplant doctors, who will contact you with an appointment. Completed by:[2173-10-10]	[ "582.81", "V42.0", "038.42", "733.00", "288.50", "710.0", "272.4", "251.2", "E931.5", "276.1", "401.9", "E849.7", "008.45", "995.91", "252.00" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	14651, 14657	7433, 12962	315, 322	14799, 14799	4410, 6074	16161, 17098	3304, 3529		13399, 14628		14678, 14778		12988, 13376				14950, 15706													3544, 4391						6112, 7410														15735, 16138						244, 277							350, 2484											14814, 14926						2506, 3028	3044, 3288
14,106	121,520	2051	Discharge summary	report	Admission Date: [2133-3-1] Discharge Date: [2133-3-7] Date of Birth: [2076-7-30] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 898] Chief Complaint: fevers, cough Major Surgical or Invasive Procedure: intubation arterial line History of Present Illness: 56 yo M w/ history of hypertension, hypercholesterolemia, and chronic renal insuffiency who presented with fever & cough. Pt with cough x 2 weeks, productive of green sputum, and also rhinorrea. His cough has been constant, although it loosens up in the shower, over the past 2 weeks. He has been increasingly thirsty, and not sure he is taking in much po. Emesis x 1 in ED today, mucus, otherwise no nausea/vomiting/diarrhea or abdominal pain. No chest pain, no myalgias. Per pt's wife, they have been passing around the flu in their family. Pt has not had the fluc vaccine or pneumovax. In the ED, cxr was negative for infiltrate, but pt received ceftriaxone/azithro for presumed pneumonia. Admitted to medicine. Past Medical History: - Hypertension - Hypercholesterolemia - Chronic renal insuffiency (followed by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 174] in the past and now by [First Name8 (NamePattern2) 3122] [Doctor Last Name 1860]- baseline creatinine unknown- last one here 3.5 in [2130]) - Atrophic right kidney (of unclear etiology) - Obesity Social History: occasional cigarette since young and occasional ETOh, married, project manager for steel company Family History: no kidney disease, father with hx of MI age 79 Physical Exam: T 101.6 BP 121/55 HR 118 rr 16 O2 92% RA -> 97% on 4L genrl: awake & alert, speaking comfortably in full sentences, in NAD heent: perrla, sclera anicteric, op clear, dry mm cv: tachy w/ rr, no m/r/g pulm: diffuse expiratory wheezes bilaterally abd: nabs, soft, nt/nd extr: no c/c/e Pertinent Results: [2133-3-1] 02:58PM WBC-12.2* RBC-3.83* HGB-11.8* HCT-35.2* MCV-92 MCH-30.8 MCHC-33.5 RDW-12.6 [2133-3-1] 02:58PM PLT COUNT-239 [2133-3-1] 02:58PM NEUTS-86.6* LYMPHS-9.2* MONOS-3.8 EOS-0.1 BASOS-0.3 [2133-3-1] 02:58PM GLUCOSE-131* UREA N-69* CREAT-6.3# SODIUM-136 POTASSIUM-5.3 CHLORIDE-101 TOTAL CO2-20* ANION GAP-20 [2133-3-1] 04:26PM LACTATE-1.7 Brief Hospital Course: - respiratory failure - at admission, pt c/o cough/fevers, with negative cxr, suggestive of influenza. He was placed on respiratory isolation, and admitted to the medicine service. The morning after admission on [3-2], he was found by his nurse to be unresponsive. He was last seen approximately at 0730 per vitals sheet, but didn't receive nebs overnight as ordered. He was poorly responsive, awake, but agitated and uncooperative with audible gurgling sounds. ABG at this time was 7.18/54/135- respiratory code called for intubation of hypercarbic resp failure. He was given 2amps of bicarb, intubated without complication and lots of thick secretions suctioned via ETT. Admitted to ICU. He remained stable on the ventilator, and his vent settings were quickly weaned down. He was thought to have had a mucus plug, in the setting of a respiartory illness. The following day, he had some difficulty extubating due to anxiety, but then was easily extubated without complication the following day. He was initially on oxygen via nasal cannula, which was quickly weaned off, and he had no further respiratory issues. - influenza - pt admitted with cough/fevers, in setting of presumed exposure to influenza; in addition, he had not recieved influenza vaccine; this constellation of symptoms was thought most likely to be influenza. He did receive antibiotics(ceftriaxone/azithro) empirically in the ED, but these were d/c'd as there was no evidence of infiltrate on cxr. He was placed on respiratory isolation, and indeed did rule in for influenza. He was not treated as he had sypmtoms for over 48 hours. His fevers resolved soon after admission, and no other source of infection localized. - ARF - pt with chronic renal insuffiency at baseline, in setting of atrophic right kidney. His creatininewas 6.3 at admission, up from baseline of 3.5. This was thought most likely to represent ATN in setting of decreased po intake, fevers, viral illness while in diuretics. His creatinine peasked at 6.5. With hydration, his creatinine gradually trended down. The renal consult service followed him throughout his stay. In addition, he had a renal ultrasound, confirming an atrophic right kidney, and a left kidney cyst. Creatinine leveled at 43 at discharge, which was thought to possibly be his new baseline. He was then restarted on an ACE inhibitor. He was scheduled for outpatient monitoring of his kidney function. He also was scheduled to follow up with Dr. [Last Name (STitle) 1860] on the renal service as an outpt. - left kidney cyst - visualized on renal ultrasound obtained for workup of ARF. This was thought likely to represent a cyst, but an MRI was recommended to confirm absence of any malignancy. This was ordered, but did not occur while pt was in-house. He was scheduled for an outpt renal MRI to f/u on this. - gout - noted to have left knee pain & erythema. This was tapped, which was negative for any infectious etiology. He was started on prednisone, as other forms of gout treatment would be contraindicated given his ARF, with much improvement. Discharged on a prednisone taper. - anemia - pt with iron-deficiency anemia, and also with anemia [2-4] CKD. He was continued on iron. He also is planned to start on epogen as outpt, to be coordinated by Dr. [Last Name (STitle) 1860]. - hypertension - on metoprolol, lasix, & ace as outpt. At admission, his diuretics were held [2-4] ARF. He was maintained on metoprolol. The day of discharge, he was restarted on lisinopril as per the renal team, with plans for outpt lab monitoring. Medications on Admission: toprol 50mg qd lisinopril 15mg qd lipitor 40mg qd tylenol #3 prn lasix 40mg qd Discharge Medications: 1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 150 mg/15 mL Liquid Sig: [1-4] PO BID (2 times a day). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) tab PO BID (2 times a day). Disp:60 tab Refills:2 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for 9 days: 6 tabs po x 1 day then 5 tabs po QD x2days then 4 tabs po QD x 2days then 2 tabs po QD x2days then 1 tab po QD x2days then stop. Disp:30 Tablet(s) Refills:0 11. Outpatient Lab Work chem-10 on Monday, [3-9], results to Dr. [Last Name (STitle) 1860] at [Telephone/Fax (1) 60] Discharge Disposition: Home With Service Facility: [Hospital3 ] [Hospital3 269] Discharge Diagnosis: PRIMARY: - hypercarbic respiratory failure - acute renal failure - influenza - hyperkalemia - kidney mass - gout - fevers - CK/troponin leak [2-4] demand ischemia - acidosis - iron-deficiency anemia SECONDARY: - hypertension - hypercholesterolemia - chronic renal insuffiency - anemia due to chronic renal insuffiency - atrophic right kidney - obesity Discharge Condition: stable to home w/ [Name (NI) 269], PT Discharge Instructions: - Take medications as directed. You are now taking a lower dose of lisinopril, and are not on lasix. You have been started on iron for your anemia. You will be on a prednisone taper for your gout. - Follow up as scheduled. - Call your doctor or seek medical attention for decreased urine output, fevers, chills, dizziness, shortness of breath, chest pain, or other concerning symptoms. Followup Instructions: - Follow up with your primary care physician [Last Name (NamePattern4) ] 1 week. Call after discharge to make appointment. - You need your potassium and kidney function checked on Monday, [3-9]. Lab slip attached. - Follow up for renal MRI. This has been ordered - call the radiology scheduling department to schedule at [Telephone/Fax (1) 327]. Recommend obtaining MRI next week. - Follow up with Dr. [Last Name (STitle) 1860] in renal on Monday. Call her office on Monday morning to arrange time at [Telephone/Fax (1) 60]. - You will need to be started on epo injections as outpatient, Dr. [Last Name (STitle) 1860] to arrange. Completed by:[2133-6-4]	[ "403.91", "274.0", "276.5", "518.81", "593.9", "584.9", "272.0", "487.1", "280.9", "276.2" ]	icd9cm	[ [ [] ] ]	[ "96.04", "81.91", "96.71", "38.91" ]	icd9pcs	[ [ [] ] ]	7302, 7369	2384, 5989	326, 353	7770, 7813	1980, 2361	8250, 8938	1615, 1663		6118, 7279		7390, 7749		6015, 6095				7837, 8227													1678, 1961																										273, 288							381, 1106																	1128, 1485	1501, 1599
27,108	137,499	10654	Discharge summary	report	Admission Date: [2154-6-16] Discharge Date: [2154-6-21] Date of Birth: [2093-3-27] Sex: M Service: MEDICINE Allergies: Atorvastatin / Imdur Attending:[First Name3 (LF) 613] Chief Complaint: Epigastric Pain, Diarrhea Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 61M w/ CAD, DM2, HTN, presented to [Hospital3 3583] [6-16] with epigastric pain, nausea, vomiting, and diarrhea. This AM, he ate bacon and eggs at a restaurant. Two hours later, he had profuse diarrhea, nausea, dry heaving. He noted his stools were dark brown but denies black tarry stools or BRBPR. He has also had a cough x 3 days, nonproductive. Denies fever/chills. No sore throat, travel, sick contacts. [Name (NI) ] came to the [First Name4 (NamePattern1) 46] [Last Name (NamePattern1) ] this afternoon. His BP was noted to be 76/56 with HR 94. He was given 3L NS, Zofran, Reglan, and was started on dopamine. He was sent for CT to r/o mesenteric ischemia. In the CT scanner, he developed chest pain. Repeat ECG showed inferior ST elevations. He was started on heparin, and was given morphine, Plavix 600mg po, and Zofran, and transferred to [Hospital1 ] for cath. . In the cath, he had patent LAD and LCX stents, and unchanged chronic total occlusion of RCA. He was given 400cc NS and weaned off dopamine. He was admitted to the [Hospital1 1516] service. On arrival to the floor, a trigger was called for BP 70/40 with HR 118. He was given 1L NS bolus with no response. He was started on dopamine. He was taken for a CT to r/o RP bleed, which was negative. He was transferred to the CCU. . On arrival to the CCU, he complained of mild chest pressure. His dopamine was switched to levophed, and his chest pain resolved. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis. 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, palpitations, syncope or presyncope. In the CCU, he was aggressively volume repleted with a total of 18L, on 2 L O2. He was subsequently given lasix 20 IV and diuresed well. Insulin gtt switched to Lantus; was on metformin when he was admitted. Being tx for sepsis of unknown source with Cipro/Flagyl, no further fevers. Ct abdomen and U/S negative, c.diff negative, covering for UTI/GI coverage. BP 150s, restarted bp meds, LFTs elevated, increased statin, ACE holding. b/l Cr 1.1, currently 1.5, cardiac enzymes trop and CK elevated from demand ischemia. Past Medical History: PAST MEDICAL HISTORY: 1. CAD: IMI [2141], s/p PCI to RCA 2. Hypertension 3. Hyperlipidemia 4. Type 2 Diabetes 5. Obstructive sleep apnea- nasal CPAP 16cm at home 6. GERD 7. Depression 8. Gout 9. s/p bilateral knee arthroscopy 10. s/p remote hernia repair 11. Erectile dysfunction Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension . Percutaneous coronary intervention, in [1-22] anatomy as follows: chronic total occlusion of RCA at mid vessel with long occluded area in the stents and 80% stenosis in the acute marginal Social History: Social history is significant for history of tobacco use, 1 pack a day x 19y, quit in [2129]. There is no history of alcohol abuse. Family History: Brother with an MI in his late 50's and another in his 60??????s. Physical Exam: VS: T 100.0, BP 118/48, HR 129, RR 21, O2 91% on Gen: obese man lying flat in bed, NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclerae anicteric. Conjunctivae pink, no pallor or cyanosis of the oral mucosa. Neck: Supple. Unable to assess JVP due to large diameter of neck. CV: Unable to palpate PMI. Tachycardic but regular, normal S1/S2. No murmur. Chest: Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Obese, soft, mild diffuse discomfort to deep palpation, ?worse in RUQ. Ext: Feet warm and well-perfused. Trace LE edema bilaterally. R cath site with dressing c/d/i. Pulses: Right: Carotid 2+; Femoral 2+ without bruit; DP Dopplerable Left: Carotid 2+; Femoral 2+ without bruit; DP Dopplerable . Pertinent Results: RUQ Ultrasound:IMPRESSION: Cholelithiasis without evidence for acute cholecystitis. CT ABDOMEN: IMPRESSION: 1. Trace amount of free fluid in the pelvis, measuring approximately 1.1 x 1.9 x 2.6 cm, likely a sequela of recent procedure, but not large enough to explain hypotension. No retroperitoneal or groin hematoma. 2. Small bilateral pleural effusions with associated atelectasis. 3. Gallstones without evidence of cholecystitis. 4. Somewhat atrophic left kidney. 5. Extensive degenerative disease of the lumbar and lower thoracic spine. C. CATH COMMENTS: 1. Coronary angiography in this right-dominant system revealed: --the LMCA had no angiographically apparent disease. --the LAD had mild luminal irregularities, with widely patent stent --the LCX had mild luminal irregularities, with widely patent stent --the RCA had a chronic distal occlusion unchanged from prior. 2. Limited resting hemodynamics revealed normal systemic arterial systolic pressures, with SBP 109 mmHg. 3. Successful closure of right femoral arteriotomy site with 6-French Angioseal device. FINAL DIAGNOSIS: 1. One-vessel coronary artery disease with occluded RCA unchanged from [2154-1-15] 2. Demand collateral insufficiency in setting of hypotension and tachycardia Brief Hospital Course: 61M w/ CAD s/p IMI, DM2, with epigastric pain, hypotension, fever, concerning for sepsis. Initially transferred to [Hospital1 18] CCU for cardiac cath in setting of developing chest pain in the CT scanner at OSH. . # CAD: Pt had ST elevation at OSH while on dopamine and was transferred here for cardiac catheterization. The Cath report showed widely patent LAD and LCX stents, chronic distal occlusion of RCA unchanged from prior. It was felt his ST elevations were most likely secondary to collateral insufficiency in setting of hypotension, tachycardia, and dopamine. Repeat EKG's unchanged from baseline once off the dopamine. Continued ASA, Statin, metoprolol was titrated up and sent home on 75mg PO TID. Lisinopril was restarted and increased to 20mg at time of discharge. . # Hypotension The patient presented with hypotension and had been on dopamine while undergoing a cardiac catheterization. However, post procedure, the pt remained persistently hypotensive and was thus transferred to the CCU for ongoing care. Initially there was concern that his hypotension may be secondary to an RP bleed and a CT Abdomen was done which showed no pathology or RP bleed. He was suspected to have sepsis as the cause given his subsequently noted leukocytosis (WBC 28), anion gap acidosis, low-grade fever 100. He was bolused with ongoing IVF and placed on Levophed. It was felt that the most likely source was intraabdominal given localizing symptoms on presentation including nausea and diarrhea. There was also a possibility of cholecystitis given known gallstones, however RUQ ultrasound did not show evidence of this. A CXR without evidence of infiltrate. U/A mildly positive. Cortisol WNL. He was initially covered with broad spectrum antibiotics including vancomycin, Zosyn and Flagyl for possible GI source. He was resuscitated with 20 Liters of IVF and weaned of Levophed. It was felt that ultimately his hypotension was multifactorial including acute gastroenteritis on top of what was likely chronic diarrhea with dehydration and some DKA/osmotic diuresis from poorly controlled sugars. Given he remained afebrile and WBC improved to 6.0, his antibiotics were change to Ciprofloxacin to complete a 7 day course for a presumed UTI. . # Pump: Pt had ECHO showing EF 55% with symmetric LVH. After fluid resuscitation pt with some increased SOB and mild volume overload. He was subsequently diuresed with IV Lasix given he was 18 liters positive when transferred out of CCU. He diuresed extremely well and was discharged on 60mg of oral Lasix with close PCP follow up, his prior dose had been 40mg. He was off oxygen and cleared by PT for discharge home once he was diuresed appropriately. . # ARF: Likely [2-16] poor forward flow in setting of hypotension. His creatinine decreased to 0.9 with aggressive diuresis indicating he was off the starling curve and overloaded. . # Metabolic acidosis: Initially a gap acidosis, subsequently closed after aggressive IVF, insulin and antibiotics. Likely multifactorial from infection/sepsis + DKA + Normal saline. . # DM2: Blood sugars elevated in 300s on admission; was on insulin gtt and now titrating off gtt and starting Lantus 25U which was increased to 40 units daily at the time of discharge. Home Metformin was held. He will need sugars monitored closely, he has appointment with his PCP early next week. . # HTN: Discharge regimen of lisinopril 20mg, metoprolol 75mg tid . # OSA:Continued on home CPAP Medications on Admission: ASA 325mg daily Metoprolol 50mg daily (?) Metformin 1000mg [Hospital1 ] Lisinopril 10mg daily Sertraline 50mg daily Protonix 40mg daily Allopurinol 300mg daily Simvastatin 80mg daily Lasix 40mg daily Glimepiride 4mg daily MVI Ferrous sulfate 325mg daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO three times a day: 75 mg 3 times a day. Disp:135 Tablet(s) Refills:0 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. 7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 8. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:60 Tablet(s) Refills:9 9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:10 Tablet(s) Refills:0 10. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units Subcutaneous once a day. Disp:1500 units Refills:0 11. Multivitamins Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: Bayada Nurses Inc Discharge Diagnosis: CAD with acute coronary syndrome acute renal failure UTI diabetes mellitus, type II, uncontrolled with complications obstructive sleep apnea Discharge Condition: stable, on room air oxygen, cleared by PT for discharge home Discharge Instructions: You were admitted with chest pain, heart cath showed no new blockages in your heart. You also had low blood pressure which is likely due to a urine infection. You were given plenty of intravenous fluids and need to urinate off a lot of that fluid. Your blood pressure medication was increased as well, your metformin and glimepiride were stopped and you were placed on glargine 40 units daily (insulin), your primary care doctor will decide whether or not to restart your metformin when you see him early next week. You will need to see your outpatient doctor early next week to check your blood work and adjust your lasix (water pill), diabetes medications and your blood pressure medications. If you develop any chest pain, shortness of breath, fever or any worrisome symptoms call his office or present to the emeregency room to be evaluated. Followup Instructions: [Last Name (LF) ],[First Name3 (LF) 177] A. [Telephone/Fax (1) 5315] early next week follow up with your cardiologist within the next 4 weeks [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617]	[ "276.51", "787.91", "410.71", "599.0", "276.2", "327.23", "V45.82", "428.33", "401.9", "414.01", "558.9", "414.2", "250.12", "584.9" ]	icd9cm	[ [ [] ] ]	[ "37.22", "93.90", "88.56" ]	icd9pcs	[ [ [] ] ]	10589, 10637	5640, 9130	306, 331	10822, 10885	4358, 5433	11779, 12058	3479, 3546		9439, 10566		10658, 10801		9156, 9416		5450, 5617		10909, 11756													3561, 4339																										241, 268							359, 2746																	2790, 3309	3325, 3463
6,069	130,702	4575	Discharge summary	report	[ ] Date: [2117-2-28] Discharge Date: [2117-3-5] Service: NEUROLOGY Allergies: Codeine / Versed / Colchicine / Lipitor Attending:[First Name3 (LF) 2569] Chief Complaint: Left sided weakness Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [Known lastname 19444] is a lovely 91-year old woman with a history of paroxysmal atrial fibrillation off coumadin secondary to remote GI bleeds who presents with acute onset of left sided weakness and slurred speech. Patient was with her nephew [Location (un) 1131] [Initials (NamePattern4) ] [Name (NI) 19450] [Last Name (NamePattern1) ] card. At 630 she tried to put her glasses on with her right hand but kept missing her head. She then began drooling out of her left mouth and speech was slurred. Her nephew, who is an ophthlamologist and her health care proxy called 911, and he tried to test her strength. He asked her to squeeze his hands, and her left side was clearly weaker. At one point after the onset of the weakness he also saw some rhythmic jerking of her left hand which self-resolved. By the time she was brought via EMS to [Hospital1 18], she was no longer speaking, somnolent, and not responding to most questions, though she was seen to raise her right arm once in response to command. A CODE STROKE was called at [2017]. . Of note, ED course was also notable for elevated K at 6.[Street Address(2) 19451] changes for which she was given calcium, insulin, glucose with improvement to 5.6 but subsequent relative hypoglycemia at 60 for which she was given [1-17] amp D50. Past Medical History: # Hypertension # Atrial fibrillation, diagnosed [2108] c/b R arm thrombus # S/p CVA to L insula [12/2112] w/ very mild right facial asymmetry and some attentional/memory problems # Mild cognitive impairment/occasional sundown syndrome # Colonic GI bleed x 4 ([2111], [2112], [2113], [2114]) - coumadin stopped # Diastolic and Systolic Heart Failure # Moderate Mitral regurgitation # Moderate Aortic regurgitation # Diverticulosis # Gout # Amiodarone-induced hypothyroidism, [11/2115] # H/o E.Coli & VRE UTI, [2112] # Right cataract surgery, [2114] # Dyspepsia # S/p R breast excision ([5-/2112]) atypical ductal hyperplasia # S/p open appendectomy in [2052] # Compression fracture of thoracic vertebrae in [4-/2116] # Surgical repair of broken right hip in [6-/2116] # Small aneurysm of aortic arch noted on echocardiogram [11/2116] Social History: Patient lives alone in [Location (un) 2312] since the death of her husband 9 year ago. She has no children, but has a very supportive nephew and [Name2 (NI) 802] who visit her frequently and help her with her medications and appointments. She is retired, but previously worked as a "stitcher" for many years. Tobacco: Never. EtOH: drank wine with dinner, quit after her stroke in [2112]. Illicits: Never. Contact [Name (NI) 19447]: HCP/Nephew: [Name (NI) ] [Name (NI) 19442], MD [Telephone/Fax (1) 19443]. Family History: No hx of colon cancer of GI bleeds. Females have a history of mitral valve prolapse. Mother died of CHF/diabetes. Father died of MI. Physical Exam: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: irregularly irregular, no M/R/G noted Abdomen: soft, NT/ND, no masses or organomegaly noted. Extr: WWP Skin: no rashes or lesions noted. Neurologic: Fluent speech. A&O x3. Able to digit span forward to 5 and backwards to 3. Unable to copy a cube or make a clock correctly. No neglect. CN: PERRRL, EOMI, Face symmetric. Tongue midline, SCM's full. Motor: strength was 4+/5 and symmetric in upper and lower extremities. Cordination: FNF no ataxia Gait: With [Telephone/Fax (1) ], stable. wide based. Pertinent Results: MRI head: IMPRESSION: 1. No acute ischemia. 2. Age-appropriate atrophy, and chronic small vessel ischemic changes. 3. There is no occlusion or flow-limiting stenosis of the arterial system of the head and neck. Brief Hospital Course: Ms. [Known lastname 19444] is a 91-year old woman with a history of paroxysmal atrial fibrillation off coumadin secondary to remote GI bleeds who presents with acute onset of left sided weakness and slurred speech with some evidence of left hand shaking but only after onset of deficits. Initial exam showed marked somnolence, mutism, left facial droop, decreased movement of left relative to right with relative preservation in sensory modality, and visual field cut on left. Her NIHSS was 28. Her head CT showed no acute bleed or well-developed infarct. Given the acute onset of left-sided weakness preceding any shaking as well as the history of atrial fibrillation off of coumadin, stroke was deemed more likely than seizure, though seizure was considered as a differential diagnosis. A 1 mg ativan dose was given as trial to stop seizure without effect. Further was not given due to concern of somnolence affecting respiration. Given the elevated NIHSS and absence of absolute contraindications, though multiple relative contraindications were noted, discussion was had with her nephew/HCP whether to give TPA. After extensive discussion with regarding the potential risks and benefits of TPA in this case with particular consideration to history of GI bleeds, old age, possibility, and possibility of a seizure contributing to weakness/somnolence, and her desire not to live if she were to have any additional deficits, the decision was made to proceed with TPA. TPA Bolus was given at 831, about 120 minutes after symptom onset. Within 20 minutes of dose being given clear improvement was seen. By 30 minutes post-TPA patient was still somnolent but arousable to voice or gentle tactile stimulation, eyes closed at rest. She could state her name, where she lives, identify her nephew. Extraocular movements were full, tongue midline. Facial weakness was mostly resolved. She could elevate both arms to 45 degrees for at least 10 sec though persisted with grip weakness on the left relative to right. She could elevated both lower extremities for 5-7 seconds. She had withdrawal responses to noxious stimulation bilaterally. She denied any headache. Plan was made for repeat CT en route to neuro-ICU with subsequent [Known lastname ] to neuro-ICU. An MRI/A did not demonstrate any acute ischemia, occlusion, or flow limiting stenosis. She was initially sent to the ICU for observation then to the Med floor where she had a stable course. She was discharged to home given baseline exam. She was given a prednisone taper for acute gout flare. She was CKD so colchicine was not given. Her Antiplatlet ASA was not changed after the event. It was postulated that the event was not vascular in nature but secondary to a seizure. Medications on [Known lastname ]: levothyroxine 100 mcg daily lasix 20 mg M/W/F Prilosec M/W/F Lisinopril 20 mg daily 2 senna QHS PRN Metoprolol XR 50 mg daily Fosamax 70 mg qweek Aspirin 325 mg daily Tylenol 500 mg daily Tums 2 tab daily Vitamin D 1000 IU daily Vitamin B12 [Numeric Identifier 961] mcg daily Colace 100 mg daily 500 mg cranberry extract Discharge Medications: 1. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for constipation. 4. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 8. prednisone 10 mg Tablet Sig: See titration schedule Tablet PO once a day for 10 doses: [2117-3-5] take 30mg [2117-3-6] take 20mg [2117-3-7] take 10mg then stop. Disp:6 Tablet(s) Refills:0 9. quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for aggitation. 10. lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Seizure with post-ictal paralysis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid ([Name (NI) ] or cane). Discharge Instructions: You were admitted as a code stroke and were a t-Pa candidate. You received this medications and you were observed in the ICU. You had an MRI that had no evidence of stroke. You had a high potassium and your lisinopril was cut to 10 mg daily because of this. There were no other changes to your medications. On the day prior to your discharge you were started on a prednisone taper for a gout flare affecting your feet. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Neurology Dr [First Name8 (NamePattern2) 2530] [Name (STitle) ]. Date/Time Monday [4-19] at 3pm. Please call [Telephone/Fax (1) 2574] one week prior to your appointment to ensure time and date. [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575] Completed by:[2117-3-9]	[ "428.42", "428.0", "244.3", "276.7", "403.90", "293.0", "274.01", "784.3", "585.9", "285.9", "E942.0", "780.39", "427.31", "342.92" ]	icd9cm	[ [ [] ] ]	[ "99.10" ]	icd9pcs	[ [ [] ] ]	8377, 8448	4228, 7350	266, 273	8526, 8526	3992, 4205	9253, 9604	3125, 3262		7373, 8354		8469, 8505						8721, 9230													3277, 3973																										206, 228							302, 1644											8541, 8697						1666, 2558	2574, 3109
55,701	179,714	2697	Discharge summary	report	Admission Date: [2117-7-29] Discharge Date: [2117-8-6] Date of Birth: [2059-9-20] Sex: M Service: SURGERY Allergies: Dilaudid Attending:[First Name3 (LF) 473] Chief Complaint: Common bile duct stones Cholecystitis Major Surgical or Invasive Procedure: [2117-7-29]: 1. Open cholecystectomy with open common bile duct exploration. 2. Choledochoduodenostomy biliary bypass. History of Present Illness: Mr. [Known firstname ] [Known lastname 13427] is a 57 y/o malnourished men with a history of common bile duct stones and impacted gallbladder not treatable by endoscopic measures. He has a history of multiple abdominal procedures over the years culminating in total gastrectomy with Roux-en-Y jejuno-esophagogastrostomy anastomosis. He has had gastric ulcers for over 30 years. Patient on chronic TPN use at home. Also, patient has a history of COPD, he is not using home O2 and reports that his COPD is stable for long time. Past Medical History: PMH: PUD, gastric atony, COPD, Malnutrition, on TPN at home x few years PSH: s/p BII distal gastrectomy '[93], s/p complection gastrectomy, rny esophagojejunostomy '[03] Social History: He is a current smoker. He has been smoking for over 40 years, at most at 4 packs daily. In the last year he has cut down and is now smoking 6 cigs/day. No current cravings in the hospital. No EtOH use in years. No drug use. No other inhalants. He worked as a carpenter for years and believes he has had some asbestos exposure with this. He has a cat at home; no other animal exposures including no birds. Family History: His brother recently died of lung cancer, also had COPD. Wife died 15 years ago from CVA. Physical Exam: On Discharge: 98.8, 86, 124/64, 16, 94% on 1 L n/c Gen: Cachectic male, appears older than stated age CV: RRR, no m/r/g Pulm: Bilateral anterior/posterior expiratory wheezes, R > L Abd: Slightly distended, midline incision open to air with steri strips c/d/i Extr: Thin, warm, no e/c. Coccyx: Stage 2 ulcer with mepilex dsg Pertinent Results: [2117-7-29] 05:25PM BLOOD WBC-5.7 RBC-4.35* Hgb-7.1* Hct-25.5* MCV-59* MCH-16.3* MCHC-27.9* RDW-22.9* Plt Ct-263 [2117-7-30] 01:40AM BLOOD Glucose-130* UreaN-17 Creat-0.6 Na-131* K-4.0 Cl-100 HCO3-24 AnGap-11 [2117-7-30] 01:40AM BLOOD AlkPhos-708* Amylase-41 TotBili-1.6* [2117-7-30] 01:40AM BLOOD Albumin-2.5* Calcium-7.4* Phos-4.3 Mg-1.7 Iron-227* [2117-8-3] 04:18AM BLOOD Temp-37.1 pO2-227* pCO2-47* pH-7.43 calTCO2-32* Base XS-6 Comment-NON-REBREA [2117-8-4] 04:34AM BLOOD WBC-4.9 RBC-3.86* Hgb-7.9* Hct-26.6* MCV-69* MCH-20.3* MCHC-29.5* RDW-26.4* Plt Ct-280 [2117-8-6] 06:10AM BLOOD Glucose-159* UreaN-26* Creat-0.6 Na-139 K-4.8 Cl-106 HCO3-26 AnGap-12 [2117-8-6] 06:10AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.2 MICROBIOLOGY: [2117-7-29] 1:22 pm SWAB BILE. FINAL REPORT [2117-8-3] GRAM STAIN (Final [2117-7-29]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [2117-8-3]): ESCHERICHIA COLI. SPARSE GROWTH. ESCHERICHIA COLI. RARE GROWTH. SECOND MORPHOLOGY. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| ESCHERICHIA COLI \| \| AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- 8 S 4 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R =>16 R ANAEROBIC CULTURE (Final [2117-8-2]): NO ANAEROBES ISOLATED. [2117-8-1] 6:54 pm MRSA SCREEN Source: Nasal swab. FINAL REPORT [2117-8-4] MRSA SCREEN (Final [2117-8-4]): No MRSA isolated. RADIOLOGY: [2117-7-29] CHEST PORT: IMPRESSION: 1. The tip of the left PICC line is positioned in the mid SVC. 2. Marked right-sided mediastinal shift, with right middle lobe atelectasis, unchanged in appearance. [2117-8-1] CHEST PORT: There is new left upper lung consolidation as well as new left basal opacity, findings that are highly concerning for interval development of aspiration or rapidly progressing infection. Small right pleural effusion is unchanged. There is also no change in the right mediastinal shift. There is no evidence of pneumothorax. [2117-8-1] CHEST CTA: IMPRESSION: 1. No evidence of central pulmonary embolism or acute aortic pathology. 2. Right middle lobe complete atelectasis/collapse with cardiomediastinal shift to the right. 3. Asymmetric left pulmonary interstitial edema [2117-8-2] CHEST PORT: FINDINGS: In comparison with the study of [8-1], there is continued increased opacification involving much of the left lung. The findings are again worrisome for diffuse aspiration or pneumonia. Mediastinal shift to the right is again seen. [2117-8-2] ABD PORT: IMPRESSION: No evidence of ileus or obstruction. [2117-8-3] CHEST PORT: FINDINGS: In comparison with the study of [8-2], there appears to be some decrease in the diffuse opacification involving much of the left lung. Again, the findings are concerning for diffuse aspiration or pneumonia. Mediastinal shift to the right is again seen. Brief Hospital Course: The patient was admitted to the General Surgical Service for treatment of his chronic cholecystitis and cholelithiasis . On [2117-7-29], the patient underwent open cholecystectomy with open common bile duct exploration and choledochoduodenostomy biliary bypass, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor NPO, on IV fluids and antibiotics, with a foley catheter, and epidural catheter with Bupivacaine and Morphine PCA for pain control. Post operatively patient had hypotension with SBP 70-80s, which was corrected with fluid boluses. On POD # 1, Acute Pain service increased patient's bupivacaine rate and after that patient's SBP decreased to 66. Patient was triggered, APS was called and epidural catheter was removed. After removal of epidural, patient's SBP improved to 110-120s and continue to be WNL during hospitalization. Post-operatively, the [Hospital 228] hospital course is as follows by systems: Neuro: Patient has a history of chronic Percocet use for his chronic pain. Post operatively, patient was started on epidural with bupivacaine and Morphine PCA. Epidural was discontinued on POD # 1 s/t low blood pressure. Patient was continue on Morphine PCA with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. Currently he is on Oxycodone 10-15 mg Q4H. Patient instructed to continue f/u with his PCP regarding chronic pain management and refills for pain medication. CV: On POD #1, patient had episodes of hypotension, which though to be related to epidural catheter. After removal of epidural catheter, patient's BP was WNL. The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: Patient is a current smoker and has a history of COPD. Postoperatively his O2 Sats were 99% on 3L n/c. Pulmonology was consulted and their recommendations were followed. On POD#3, patient was triggered, he desaturated to 70s on 5L n/c and patient was transferred in ICU for further management. In ICU, chest radiogram was concerning for new onset of pneumonia. Patient was started on antibiotics and aggressive nebulizers. On POD # 4, patient's respiratory status stabilized and he was transferred back on the floor. On the floor patient was continue on supplemental O2, abx and nebulizers treatment. Pulmonology recommended home O2 on discharge with nebulizers. Patient has stable O2 Saturation of 94-95% on 1L n/c and 87-88% when ambulates on RA. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids, TPN was started on POD #1 as patient chronically depended on TPN. Post operatively, diet was advanced when appropriate. Patient tolerated clears and some full liquids only. Patient was discharged on regular diet with instructions to eat as much is he can PO, and continued TPN. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. Patient's PCP will following on patient's weekly TPN labs. ID: Patient remained afebrile and without leukocytosis during hospitalization. He will continue on one week of Po antibiotics after discharge for treatment of his pneumonia. Endocrine: The patient's blood sugar was monitored throughout his stay and was WNL. Hematology: The patient's complete blood count was examined routinely; no transfusions were required. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating clear/full liquid diet, ambulating, voiding without assistance, and pain was well controlled. Prior discharge, staples were removed from incision and steri strips applied. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Albuterol 90, Klonipin 0.5", Cyanocobalamin 1000 monthly, Advair 250/50, Folic 1, Mirtazapine 30, Naptroxen 250", Oxytcodone 10"', Protonix 40", Tiotropium 18 INH, Mag Oxide 400", Trazadone 50-100 hs, Excedrin 500/65 prn Discharge Medications: 1. Home oxygen 2L continuous pulse dose for portability COPD MH# [Telephone/Fax (5) 13428] Pt needs portability 4-8hrs per week for [Last Name (NamePattern4) 4113] appointments and activities 2. Nebulizer Home nebulizer machine and all necessary accessories MH# [Telephone/Fax (5) 13428] Dx COPD 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [Hospital1 ] (2 times a day). Disp:1 dose disc Refills:2 4. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) neb Inhalation every six (6) hours. Disp:120 neb Refills:2 5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for sleep. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. 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:2 9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:2 10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 11. Oxycodone 5 mg Tablet Sig: 2-3 Tablets PO every four (4) hours as needed for pain. Disp:140 Tablet(s) Refills:0 12. 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. 13. Heparin Flush 10 unit/mL Kit Sig: One (1) Intravenous once a day: flush per lumen prn. Disp:1 box Refills:2 14. Saline Flush 0.9 % Syringe Sig: One (1) Injection once a day: flush each lumen prn. Disp:1 box Refills:2 15. Outpatient Lab Work Please check Chem10 (electrolytes, Magnesium, Calcium, Phosphate, glucose), triglycerides, transferrin, TIBC, albumin, ALT, AST, T.bili, ALP, amylase, lipase, and ferritin weekly. Fax results to [Last Name (NamePattern4) 13429], MD at [Telephone/Fax (1) 13430]. Call [Telephone/Fax (1) 3183] with questions. 16. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 86] Home Infusion Discharge Diagnosis: 1. Biliary obstruction. 2. Common bile duct stones. 3. Cholelithiasis. 4. COPD exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance. Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [4-26] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. . PICC Line: Please monitor the site regularly, and [Name6 (MD) 138] your MD, nurse practitioner, or [Name6 (MD) 269] Nurse if you notice redness, swelling, tenderness or pain, drainage or bleeding at the insertion site. * [Name6 (MD) ] your MD [First Name (Titles) ] [Last Name (Titles) 10836] to the Emergency Room immediately if the PICC Line tubing becomes damaged or punctured, or if the line is pulled out partially or completely. DO NOT USE THE PICC LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and dry. Contact your [Name2 (NI) 269] Nurse if the dressing comes undone or is significantly soiled for further instructions. . Outpatient TPN Labs: Please check Chem10 (electrolytes, Magnesium, Calcium, Phosphate, glucose), triglycerides, transferrin, TIBC, albumin, ALT, AST, T.bili, ALP, amylase, lipase, and ferritin weekly. Fax results to [Last Name (NamePattern4) 13429], MD at [Telephone/Fax (1) 13430]. Call [Telephone/Fax (1) 3183] with questions. Followup Instructions: Provider: [First Name8 (NamePattern2) 251] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 2835] Date/Time:[2117-8-30] 10:15 [Hospital Ward Name 23] 3, [Hospital Ward Name ] . Please call [Telephone/Fax (1) 3183] to arrange a f/u appointment with Dr. [Last Name (STitle) ] [Last Name (NamePattern4) ] (PCP) to continue f/u with TPNs labs and pain management in [12-19] weeks after discharge. Completed by:[2117-8-6]	[ "574.71", "533.90", "799.02", "491.21", "799.4", "041.4", "305.1", "707.03", "338.29", "789.09", "263.9", "V85.0", "458.29", "507.0", "707.22" ]	icd9cm	[ [ [] ] ]	[ "99.15", "51.41", "51.22", "51.36" ]	icd9pcs	[ [ [] ] ]	12379, 12446	5689, 9823	304, 429	12582, 12582	2086, 5666	14859, 15321	1635, 1726		10094, 12356		12467, 12561		9849, 10071				12741, 13320										13335, 14836			1741, 1741																	1755, 2067									227, 266							457, 993											12597, 12717						1015, 1196	1212, 1619
64,274	117,867	38608	Discharge summary	report	Admission Date: [2111-3-28] Discharge Date: [2111-5-12] Date of Birth: [2049-1-23] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 5569] Chief Complaint: Ischemic R Foot Major Surgical or Invasive Procedure: [2111-5-11] endobronchial ultrasound with biopsies [2111-4-30] Ex lap, lysis of adhesions [2111-4-6] R BKA [2111-3-29] aortobifem History of Present Illness: The patient is a 62-year-old male with history of bilateral avascular hip necrosis, status post bilateral total hip arthroplasty. The patient was at his rehab facility and noted increasing discomfort at his right lower extremity with diminishing sensation at the foot and some limitation of motor function. He was consented, after initial performance of angiogram demonstrating severe aorta occlusive disease Past Medical History: # COPD (unknown PFTs) # Fatty liver (presumed [2-4] alcohol) # Gastritis (never had upper EGD, never had colonoscopy) # H/o NSVT (3-4 beat run while admitted in [3-11]) # H/o tonsillectomy # Left total hip replacement [2-/2110] Social History: Quit smoking and etoh in [3-11]. Frankly denies current ethanol use, but very heavy use in past per records from OSH. History of 160 pack years tobacco ([2-6] ppd over 40-45 years). No IVDU. Currently unemployed, but formerly works as jeweler. Family History: NC Physical Exam: Vitals: 98.3 97.6 100 104/72 14 95%2LNC GEN: NAD, resting comfortably CV: RRR Lungs: CTAB ABD: Soft, slight distension, but non-tender. Incision clean, dry, and intact. Steri strips in place. Staples removed. RLE: Wound clean and dry. No edema. Pertinent Results: ECHO [2111-4-14]: IMPRESSION: Normal global and regional biventricular systolic function. Moderate pulmonary hypertension. Small pericardial effusion. CT [2111-4-19]: IMPRESSION: 1. Findings described above, likely represent resolving small bowel obstruction. 2. Patent aortobifemoral graft with adjacent surgical stranding and fluid. Although this may be post-surgical in nature, infection should be considered in the correct clinical setting. 3. Stable moderate pericardial effusion. 4. New bilateral moderate pleural effusions with adjacent compressive atelectasis, less likely underlying infectious process. 5. Mesenteric edema which may be post-surgical in nature. 6. Focal opacities in the right lateral lower lobe and lingula may represent atelectasis vs infection, however malignancy is not necessarily excluded. KUB [2111-4-22]: Progression of duodenal and proximal jejunal small bowel distention worrisome for evolving proximal small-bowel obstruction. CTA chest [2111-4-10]: IMPRESSION: 1. Bilateral pulmonary emboli without evidence of right heart strain. 2. Patchy peripheral opacities in the right middle and lower lobes, suspicious for infection. Lymphangitic spread of disease may also have this appearance. 3. Marked interval increase in size of pulmonary nodules and bilateral hilar and mediastinal lymphadenopathy with interval development or right pleural and pericardial effusions. Given this constellation of findings is highly concerning for malignancy; lymphoma and metastases should be considered, although the differential includes sarcoidosis, or cryptogenic organizing pneumonitis. Recommend correlation with bronchoscopic biopsy. [2111-4-27] Abd XR: IMPRESSION: 1. Significantly decreased distention of previously noted dilated loop of small bowel suggesting resolution of partial small bowel obstruction or ileus. 2. The nasoenteric tube is seen in appropriate position with the tip within the distal stomach and the sidehole past the gastroesophageal junction. [2111-4-28] Liver USG: IMPRESSION: 1. Dilated proximal CBD up to 9-mm with mildly prominent right hepatic duct, new since the last CT study dated [2111-4-19]. While no cholelithiasis or proximal choledocholithiasis is directly observed, obstruction at the distal CBD cannot be excluded. If clinical concern remains high, recommend MRCP for further evaluation. 2. Slightly echogenic liver compatible with known fatty liver. No focal hepatic lesions. No ascites. [2111-4-30] CT abd: High-grade small-bowel obstruction with transition point in the left mid abdomen given the swirling appearance of the vessels/bowel loops is concerning for internal hernia or volvulus. No evidence of free air. [2111-5-12] On day of discharge 136 101 25 -------------<89 4.5 25 1.0 Ca: 9.5 Mg: 1.8 P: 5.3 ALT: 35 AST: 31 AP: 442 Tbili: 1.7 11.8 > 26.4 < 314 PT: 18.2 PTT: 27.6 INR: 1.6 Brief Hospital Course: The patient was admitted to the vascular service on [2111-3-28] for an ischemic R foot. He underwent aortbifem on [2111-3-29]. The patient tolerated the procedure well. Please see operative report for more details. Post-operatively, patient was doing well. Diet was advance and pain was controlled. The right foot was monitored [Doctor Last Name ] closely for signs of improvement. After several it became very clear, that the right foot was not going to recover. Arterial non-invasives were performed that showed inadequate blood flow in the R foot. Furthermore, the patient's WBC continued to rise, reaching a peak of 31. It was decided that the patient's R foot would not survive and that R BKA was the best solution. The patient agreed and he was consented after all the risks and benefits were discussed. The patient underwent R BKA on [2111-4-6], which again went well without complication. (Please see operative note.) Postoperatively, the patient's heart rate became an issue. Prior to the BKA, he maintained a HR in the low 100s with occasional bursts into the 120s. He was titrated up on po lopressor, which was helpful in maintaining his heartrate. However, on POD2 after the BKA, patient became hypotensive with SBP in the 80-90s. He was otherwise feeling fine. The lopressor was decreased to a very small dose. However, the heartrate continued to have bursts, now with episodes into the 200s, and the patient began to fell lightheaded. As such, cardiology was consulted and they recommended getting an ECHO to rule out heart issues. This showed normal heart function. However, patient's oxygen requirement had increased, although he denied any shortness of breath. A CT chest was performed that showed extensive bilateral PEs, so patient was started on a heparin drip which was titrated to a goal PTT 60-80. The patient was transitioned to coumadin with a goal INR of [2-5]. However, the patient became supratherapeutic initially, and coumadin was held, and then the INR dropped to subtherapeutic levels, likely due to improved nutrition. Heparin drip was restarted. The patient was weaned off the lopressor as heartrate improved due to treatment of PEs. The patient's Chest CT scan also showed enlarging pulmonary nodules with mediastinal/hilar lymphadenopathy. Thoracic surgery was consulted and recommended EBUS, which is to be performed as an outpatient. The patient's appetite was quite limited after his operations. He had distension in his belly initially that improved as he passed more flatus and had bowel movements. He was given supplements to support his nutrition, and he slowly was able to take more food. However, several days after the R BKA, patient began to have more distension in his abdomen with worsening pain. A CT scan was performed that showed evolving pSBO. NGT was placed and patient was started on TPN. The NGT ultimately removed on [2111-4-21], and patient's diet was slowly re-advanced. Repeat CT scan showed improvement in the SBO, but KUB showed persistent dilated loop of small bowel. However, patient felt better clinically. His NGT was removed on [2111-4-24] and he was advanced to sips & clears. On the following day , he became nauseous and had multiple bouts of vomiting. An NGT was placed back in and he was kept NPO for the next few days. A general surgery consultation was sought in view of this persistent ileus. An Abdomina XR was done that showed dilated bowel loops. A liver UWSG was done the following day since the patient was complaining of right upper quadrant pain. It revealed a 9 mm CBD with no e/o stones in the CBD or gall bladder. He had a couple of bowel movements following a suppository. Since, he seemed to be doing better clinically his NGT was removed and he tolerated sips. The following morning his abdomen was distended and he had not passed any flatus. A CT abdomen with PO contrast was done which showed high grade small bowel obstruction. He was taken to the OR for an exploratory laparotomy by the West 1 surgery service, where he underwent an extensive lysis of adhesions on [2111-4-30]. The patient was subsequently transferred to the West 1 service. TPN was continued and the patient continued to be NPO. Diet was advanced slowly. The patient remained on a heparin gtt. Diet was advanced when appropriate first to clears and subsequently to a regular diet. When tolerated the patient was changed over to PO dilaudid. The patient was on a dilaudid PCA. Warfarin 5 was started on [2111-5-5]. The patient continued to remain on warfarin daily with a heparin GTT. On [2111-5-11], the patient's heparin gtt was held and the patient went down to the operating room for an endobronchial ultrasound with biopsies for of the prior nodules found on Chest CT. The heparin gtt was held for several hours after the procedure and it was restarted during the night. The patient also receieved coumadin that evening. On [2111-5-12], the patient obtained a RUQ ultrasound for evaluation of rising alkaline phosphatase levels, which demonstrated gallbladder sludge without notable change in intrahepatic duct size and the same extrahepatic duct size. The patient at this time was eager to leave for a rehabilitation facility. The patient was switched to Lovenox 80 [Hospital1 ] and the heparing gtt was discontinued. A dose of coumadin was given at this time. The patient's fluid status was closely monitored and adjusted as needed. The patient's WBC increased to maximum of 31 during his hospital stay, but promptly came down after his BKA operation. He had low grade fevers initially after his bypass procedure, but these initially resolved after his BKA. The patient on broad spectrum IV atbx and these were discontinued once the WBC began to trend downward. The patient remained stable from a hematologic standpoint. He was transfused two units of blood on [2111-4-8] because his HCT was 25. However, the patient was asymptomatic, and this was done mainly to help improve the healing process. At time of discharge, the patient was comfortable, pain was well-controlled. Pt was in agreement with discharge plan. Medications on Admission: acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H, oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H PRN, 3. enoxaparin 40 Subcutaneous Q 24H, docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID, albuterol sulfate 2.5 mg /3 mL (0.083 %) neb Inhalation Q6H ipratropium bromide 0.02 % Solution neb Q6H, simvastatin 10 mg, calcium carbonate 200 mg PO DAILY, tiotropium bromide 18 mcg Capsule,Inhalation DAILY (Daily), pantoprazole 40 mg Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 3. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Coumadin 1 mg Tablet Sig: TO BE DOSED DAILY BASED ON INR VALUE Tablet PO once a day. 8. acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscellaneous Q6H (every 6 hours) as needed for shortness of breath or wheezing. 9. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) SHOT Subcutaneous Q12H (every 12 hours) for 1 weeks: PLEASE GIVE UNTIL PATIENT'S INR IS THERAPEUTIC. 10. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain for 2 weeks. Tablet(s) 11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [Hospital1 ] (2 times a day) as needed for constipation. 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for SBP<100, HR<55. 14. Outpatient Lab Work Daily PT/INR at least until INR is therapeutic to goal of [2-5]. 15. Outpatient Lab Work Please obtain CBC, Chem 10, and LFT's including Alk Phos, AST, ALT, T-Bili daily for the next week. Please fax results to Dr. [Name (NI) 41400] office at ([Telephone/Fax (1) 21178]. 16. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO twice a day. Disp:120 Capsule(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital6 ] hospital- [Location (un) 246] Discharge Diagnosis: Ischemic Right Foot 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: DISCHARGE INSTRUCTIONS FOLLOWING BELOW KNEE AMPUTATION This information is designed as a guideline to assist you in a speedy recovery from your surgery. Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. ACTIVITY: There are restrictions on activity. On the side of your amputation you are non weight bearing for 4-6 weeks. You should keep this amputation site elevated when ever possible. No driving until cleared by your Surgeon. PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your leg wound(s). New pain, numbness or discoloration of your stump site. Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. Exercise: Limit strenuous activity for 6 weeks. Do not drive a car unless cleared by your Surgeon. Try to keep leg elevated when able. BATHING/SHOWERING: You may shower immediately upon coming home. No bathing. A dressing may cover you??????re amputation site and this should be left in place for three (3) days. Remove it after this time and wash your incision(s) gently with soap and water. You will have sutures, which are usually removed in 4 weeks. This will be done by the Surgeon on your follow-up appointment. WOUND CARE: When the sutures are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. Avoid taking a tub bath, swimming, or soaking in a hot tub for four weeks after surgery. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. You will be given a new prescription for pain medication, which can be taken every three (3) to four (4) hours only if necessary. Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. CAUTIONS: NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. Avoid pressure to your amputation site. No strenuous activity for 6 weeks after surgery. DIET: There are no special restrictions on your diet postoperatively. Poor appetite is expected for several weeks and small, frequent meals may be preferred. For people with vascular problems we would recommend a cholesterol lowering diet: Follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood. Additionally, some people see a reduction in serum cholesterol by reducing dietary cholesterol. Since a reduction in dietary cholesterol is not harmful, we suggest that most people reduce dietary fat, saturated fat and cholesterol to decrease total cholesterol and LDL (Low Density Lipoprotein-the bad cholesterol). Exercise will increase your HDL (High Density Lipoprotein-the good cholesterol) and with your doctor's permission, is typically recommended. You may be self-referred or get a referral from your doctor. If you are overweight, you need to think about starting a weight management program. Your health and its improvement depend on it. We know that making changes in your lifestyle will not be easy, and it will require a whole new set of habits and a new attitude. If interested you can may be self-referred or can get a referral from your doctor. If you have diabetes and would like additional guidance, you may request a referral from your doctor. FOLLOW-UP APPOINTMENT: Be sure to keep your medical appointments. The key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. Things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. Don't let them go untreated! Please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are 8:30-5:30 Monday through Friday. PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE Followup Instructions: Please call Dr.[Name (NI) 1392] office to schedule a follow up appointment in 3 wks. ([Telephone/Fax (1) 4852]. Provider: [First Name11 (Name Pattern1) 674] [Last Name (NamePattern4) 675], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2111-5-22] 1:40 Please follow up with Dr. [Last Name (STitle) ] in one week by calling ([Telephone/Fax (1) 17398] as soon as possible. Completed by:[2111-5-12]	[ "276.0", "305.1", "V43.64", "415.11", "786.6", "507.0", "427.31", "E878.2", "427.0", "571.0", "496", "783.21", "785.6", "453.40", "458.29", "416.8", "440.24", "560.81" ]	icd9cm	[ [ [] ] ]	[ "84.15", "40.11", "54.59", "88.48", "38.97", "99.15", "88.47", "39.25" ]	icd9pcs	[ [ [] ] ]	13206, 13283	4691, 10829	319, 467	13347, 13347	1747, 4668	18471, 18904	1457, 1461		11322, 13183		13304, 13326		10855, 11299				13523, 15020													1476, 1728																										264, 281				15032, 17777	17800, 18448		495, 907											13362, 13499						929, 1171	1187, 1441
11,491	189,533	15828	Discharge summary	report	Admission Date: [2187-10-6] Discharge Date: [2187-10-20] Date of Birth: [2126-1-31] Sex: F Service: The patient is deceased on [2187-10-20]. HISTORY: Patient is a 61-year-old white female with a history of colon cancer status post colostomy who woke up with a severe headache on the morning of admission. However, intubated at the scene without sedation and taken to the outside hospital where she was found to have a large subarachnoid hemorrhage, and she was subsequently Med flighted to the [Hospital1 ] for further evaluation. She was Fentanyl and Ativan on route because of agitation while on ventilatory support. At the time of admission, she current medications only include over-the-counter medications for diarrhea and she had a past medical history as stated for colon cancer. On examination, she was intubated with no response to voice or sternal rub. The pupils were 2 mm bilaterally and minimally reactive. There was no corneal reflex, no doll's eyes, and no gag reflex. Motor response: She withdrew with the lower extremities bilaterally, but there was no response in the upper extremities. Due to the clinical and historical findings, the patient was considered to have a Grade V subarachnoid hemorrhage. A ventricular drain was placed and the patient was taken urgently to the angiogram suite, where under anesthetic, the patient underwent a diagnostic angiogram with placement of coils in an intracranial dissecting left vertebral aneurysm at the level of the posterior inferior cerebellar artery. The p atient tolerated to the procedure well, went to the Neuro Intensive Care Unit in stable condition thereafter, but remained intubated and essentially unresponsive to all, but significantly deep painful stimuli for which she only withdrew the bilateral lower extremities. Throughout the remainder of the patient's hospitalization, she remained essentially comatose with occasional waxing and [Doctor Last Name 688], minimal responsiveness on examination, however, due to lack of neurologic progress and after multiple family meetings, a decision was made by the family to withdraw care, that decision being made on the [2187-10-19] after several days of intensive supportive care and control of blood pressure and adequate hydration. Nutrition had been provided and the patient had shown no indication of neurologic improved. Therefore, the patient was designed as CMO, for comfort measures only, the fact that the [10-19], and the patient was noted on the morning of the 12th to have agonal respirations and a very low systolic blood pressure of 79/45 with a eventual expiration at 12:35 pm on [2187-10-20] at which time the patient was noted to have pupils dilated and nonreactive, and no pulse and no spontaneous respirations, and the patient was declared deceased at that time. TIME OF DEATH: 12:35 pm on [2187-10-20]. [Name6 (MD) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 1133] Dictated By:[Doctor Last Name 7239] MEDQUIST36 D: [2187-10-20] 15:12 T: [2187-10-24] 11:02 JOB#: [Job Number 45507]	[ "518.81", "V10.05", "780.39", "430", "276.3" ]	icd9cm	[ [ [] ] ]	[ "88.41", "39.72", "96.72", "02.2", "96.04", "38.91" ]	icd9pcs	[ [ [] ] ]
44,789	180,262	3736+55499	Discharge summary	report+addendum	Admission Date: [2128-6-22] Discharge Date: [2128-7-16] Date of Birth: [2060-8-8] Sex: F Service: NEUROSURGERY Allergies: Hydrochlorothiazide / Lopressor / Advair Diskus / Minipress / Capoten / Zoloft / Glyburide Attending:[First Name3 (LF) 78] Chief Complaint: right sided ptosis and lateral gaze pals Major Surgical or Invasive Procedure: Coiling L ICA VP shunt History of Present Illness: 67 yo with right sided ptosis and lateral gaze palsy with dilated pupil in evolution susp for expanding aneurysm Past Medical History: PMHx: DM Asthma hypercholesterolemia Afib Social History: unknown Family History: unknown Physical Exam: PHYSICAL EXAM: O: T: BP:124 / 50 HR:62 R O2Sats Gen: WD/WN, comfortable, NAD. HEENT: right sided paralysis with pstosis Pupils: R 6 L [3-18] EOMs: Right lateral paralyses 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: [2-17] 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: right pupil 6plus, Left normal III, IV, VI: Right lateral gaze V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [4-20] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right brisk Left brisk Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Exam upon discharge: A&Ox3, MAE, follows commands, no drift Pertinent Results: [2128-6-22] 09:30PM GLUCOSE-200* UREA N-15 CREAT-0.6 SODIUM-141 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-17 [2128-6-22] 09:30PM CALCIUM-9.6 PHOSPHATE-3.5 MAGNESIUM-1.8 [2128-6-22] 09:30PM WBC-12.3* RBC-4.81 HGB-13.3 HCT-40.2 MCV-84 MCH-27.6 MCHC-33.0 RDW-14.1 [2128-6-22] 09:30PM NEUTS-91.8* LYMPHS-5.5* MONOS-2.3 EOS-0.5 BASOS-0.1 [2128-6-22] 09:30PM PLT COUNT-129* [2128-6-22] 09:30PM PT-12.6 PTT-21.7* INR(PT)-1.1 CTA [2128-6-22]: IMPRESSION: 1. Extensive, diffuse subarachnoid hemorrhage with ventricular enlargement may represent early communicating or, less likely, obstructive hydrocephalus. with blood layering in bilateral lateral ventricular occipital horns. This appears stable. 2. 4-mm saccular left carotico-ophthalmic aneurysm, directed superiorly, with relatively wide-neck. CTA Brain [6-25] IMPRESSION: 1. No significant interval change in appearance of diffuse subarachnoid hemorrhage with slight interval decrease in size of lateral ventricles. No new regions of hemorrhage identified. CT [7-2] IMPRESSION: 1. Diffuse subarachnoid hemorrhage which appears stable. Hemorrhage layering in bilateral occipital horns also stable. No new areas of hemorrhage. 2. Slight prominence of the ventricles and temporal [Doctor Last Name 534], unchanged since prior examination may reflect mild degree of hydrocephalus. Shunt catheter terminates in the third ventricle, also unchanged. 2. Decreased vessel caliber involving both posterior cerebral arteries, bilateral A2 segments, and the dominant right A1 segment which may suggest mild underlying spasm. MRI Head [7-3] IMPRESSION: 1. Mild increase in the size of the left lateral ventricle, now measuring 1.5 cm in the transverse dimension compared to the prior of 1.3 cm on the most recent CT head. Blood products noted in the left lateral ventricle, in close proximity to the region of the foramen of [Last Name (un) 2044]. It is unclear if the mild increase in the size of the left lateral ventricle is related to obstruction at the level of the foramen of [Last Name (un) 2044] by the blood products/catheter dysfunction. To correlate clinically. Consider close followup CT study to evaluate interval change or progression. 2. Tiny punctate possible acute infarcts, one in the right cerebellar hemisphere, and another one in the left occipital region, given by their appearance on the DWI and the ADC sequences. Close followup MRI study can be considered, to assess interval change, as these are very tiny in size limiting more accurate assessment. 3. Areas of subarachnoid hemorrhage in the cerebral sulci and in the sylvian fissures and basal cisterns and occipital horns of both alteral ventricles, as described above, better evaluated on the prior CT study. [7-7] CTA Brain IMPRESSION: Hyperdensity seen lateral to the head and body of the left caudate (3:19) as well as in the posterior limb of the internal capsule on the right (3:17). These were not as pronounced on previous study and may represent areas of ischemia/infarct. Diffuse subarachnoid hemorrhage with intraventricular hemorrhage stable from previous exam. VP shunt on the left frontal [Doctor Last Name 534] and EVD of the third ventricle, stable. Anterior and posterior circulations grossly normal, but awaiting re-do of study. Brief Hospital Course: 67F trans with SAH. In ambulance she was noted to have R ptosis and dilated pupil and c/o occipital HA. She was emergently brought for a cerebral angiogram and found to have a ruptured L ICA aneurysm. She was extubated on [6-23]. She was alert and oriented, 5/5 strength, PEERL with sl. R ptosis. On [6-26] she was noted to have lethargy, word finding. CTA/P shows no spasm or infarct was pan cultured for fevers with no growth from cultures. She did show signs of clinical vasospasm although radiographic studies were negative. HHH therapy was initiated and she clinically improved. Remained on Nimodipine for vasospasm prophylaxis, she did require multiple pressors to sustain SBP and Nimodipine was d/c'd overnight. On [6-28] her exam was non-focal and her nimodipine was restarted and HHH therapy was liberalized. Her exam would wax and wane and all radiographic studys were negative for spasm and infarct. On [7-3] she was found to have tremors in her RUE and face. EEG was negative for seizure. On [7-5] she received a VPS and MRI/A showed a very small punctate R cerebellar and bilat pca occipital lobe infarcts. On [7-7] she was noted to have new L sided weakness in whcih studies were negative for cause although strength appears symmetrical at this time. She was also febrile and started on emperic coverage however cultures did grow anything. LENIs were also negative for DVT. She was then transferred to the floor and she was not taking adequate PO intake. Dobhoff remianed in place for nutrition and then d/c'd prior to discharge. She is A&Ox3, MAE. no drift. Medications on Admission: unknown Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 2. Atorvastatin 20 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 3. Heparin (Porcine) 5,000 unit/mL Solution [Last Name (STitle) ]: One (1) ml Injection [Hospital1 ] (2 times a day). 4. Ezetimibe 10 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 5. Ipratropium Bromide 0.02 % Solution [Hospital1 ]: One (1) NEB Inhalation Q6H (every 6 hours) as needed for wheezing. 6. Diltiazem HCl 60 mg Tablet [Hospital1 ]: One (1) Tablet PO TID (3 times a day) as needed for keep sbp < 160. 7. Aspirin 81 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Ruptured L ICA aneurysm Discharge Condition: Neurologically stable Discharge Instructions: Angiogram with Embolization and/or Stent placement Medications: ?????? Take Aspirin 81mg (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 Followup Instructions: Please follow-up with Dr. [First Name (STitle) ] in 1 month with a CT scan of the brain without contrast. Please call [Telephone/Fax (1) 1669] to schedule this appointment. Completed by:[2128-7-16] Name: [Known lastname 2633],[Known firstname ] B Unit No: [Numeric Identifier 2634] Admission Date: [2128-6-22] Discharge Date: [2128-7-16] Date of Birth: [2060-8-8] Sex: F Service: NEUROSURGERY Allergies: Hydrochlorothiazide / Lopressor / Advair Diskus / Minipress / Capoten / Zoloft / Glyburide Attending:[First Name3 (LF) 40] Addendum: [2128-7-14] 05:40AM BLOOD WBC-6.6 RBC-3.21* Hgb-9.2* Hct-28.6* MCV-89 MCH-28.7 MCHC-32.2 RDW-18.8* Plt Ct-359 [2128-7-13] 05:25AM BLOOD WBC-6.8 RBC-3.38* Hgb-9.5* Hct-30.3* MCV-90 MCH-28.0 MCHC-31.2 RDW-17.0* Plt Ct-381 [2128-7-12] 02:17AM BLOOD WBC-6.9 RBC-3.03* Hgb-8.7* Hct-26.8* MCV-89 MCH-28.6 MCHC-32.3 RDW-16.6* Plt Ct-341 [2128-7-11] 02:09AM BLOOD WBC-7.7 RBC-3.15* Hgb-9.1* Hct-27.6* MCV-88 MCH-29.0 MCHC-33.0 RDW-17.1* Plt Ct-409 [2128-7-10] 04:39AM BLOOD WBC-7.6 RBC-2.80* Hgb-8.0* Hct-24.5* MCV-87 MCH-28.4 MCHC-32.5 RDW-17.1* Plt Ct-349 [2128-7-9] 01:54AM BLOOD WBC-7.2 RBC-3.08* Hgb-8.4* Hct-27.3* MCV-89 MCH-27.4 MCHC-30.9* RDW-15.5 Plt Ct-375 [2128-7-8] 02:03AM BLOOD WBC-6.7 RBC-2.98* Hgb-8.4* Hct-25.9* MCV-87 MCH-28.3 MCHC-32.5 RDW-15.4 Plt Ct-365 [2128-7-7] 02:55AM BLOOD WBC-10.9 RBC-3.24* Hgb-9.0* Hct-27.8* MCV-86 MCH-27.9 MCHC-32.5 RDW-16.5* Plt Ct-416 [2128-7-6] 02:53AM BLOOD WBC-11.6* RBC-3.41* Hgb-9.3* Hct-29.2* MCV-86 MCH-27.3 MCHC-31.8 RDW-15.1 Plt Ct-421 [2128-7-5] 04:55AM BLOOD WBC-15.7* RBC-3.91* Hgb-11.1* Hct-34.3* MCV-88 MCH-28.2 MCHC-32.2 RDW-15.3 Plt Ct-309 [2128-7-4] 02:13AM BLOOD WBC-14.8* RBC-4.09* Hgb-11.2* Hct-35.4* MCV-87 MCH-27.5 MCHC-31.8 RDW-14.8 Plt Ct-262 [2128-7-3] 06:06PM BLOOD WBC-16.6* [2128-7-3] 03:53AM BLOOD WBC-14.8* RBC-4.39 Hgb-12.1 Hct-37.7 MCV-86 MCH-27.7 MCHC-32.2 RDW-14.7 Plt Ct-275 [2128-7-2] 02:25AM BLOOD WBC-10.4 RBC-4.66 Hgb-12.8 Hct-40.0 MCV-86 MCH-27.4 MCHC-31.9 RDW-14.2 Plt Ct-207 [2128-7-1] 01:25AM BLOOD WBC-11.2* RBC-4.28 Hgb-12.0 Hct-37.2 MCV-87 MCH-28.0 MCHC-32.2 RDW-14.2 Plt Ct-138* [2128-6-30] 02:30AM BLOOD WBC-12.8* RBC-4.58 Hgb-12.6 Hct-38.7 MCV-85 MCH-27.5 MCHC-32.5 RDW-14.4 Plt Ct-168 [2128-6-29] 02:16AM BLOOD WBC-15.2* RBC-4.63 Hgb-13.0# Hct-38.4# MCV-83 MCH-28.0 MCHC-33.8 RDW-14.8 Plt Ct-153 [2128-6-28] 03:00AM BLOOD WBC-17.0* RBC-5.83* Hgb-16.2* Hct-49.1* MCV-84 MCH-27.7 MCHC-32.9 RDW-14.6 Plt Ct-188 [2128-7-14] 05:40AM BLOOD Glucose-107* UreaN-11 Creat-0.5 Na-146* K-3.8 [2128-7-13] 05:25AM BLOOD Glucose-112* UreaN-12 Creat-0.5 Na-145 K-3.9 Cl-106 [2128-7-12] 02:17AM BLOOD Glucose-157* UreaN-15 Creat-0.5 Na-144 K-3.7 Cl-106 HCO3-33* AnGap-9 [2128-7-11] 02:09AM BLOOD Glucose-146* UreaN-14 Creat-0.6 Na-142 K-4.3 Cl-104 HCO3-33* AnGap-9 [2128-7-10] 08:58PM BLOOD K-3.6 [2128-7-10] 04:39AM BLOOD Glucose-144* UreaN-15 Creat-0.5 Na-145 K-3.5 Cl-107 HCO3-31 AnGap-11 [2128-7-9] 01:54AM BLOOD Glucose-118* UreaN-12 Creat-0.5 Na-145 K-3.9 Cl-106 HCO3-33* AnGap-10 [2128-7-8] 02:03AM BLOOD Glucose-165* UreaN-10 Creat-0.6 Na-143 K-3.8 Cl-106 HCO3-31 AnGap-10 [2128-7-7] 02:55AM BLOOD Glucose-94 UreaN-9 Creat-0.6 Na-144 K-3.6 Cl-106 HCO3-29 AnGap-13 [2128-7-6] 06:59PM BLOOD K-4.0 [2128-7-6] 02:53AM BLOOD Glucose-164* UreaN-8 Creat-0.6 Na-143 K-3.8 Cl-105 HCO3-30 AnGap-12 [2128-7-5] 04:55AM BLOOD Glucose-178* UreaN-6 Creat-0.4 Na-143 K-3.6 Cl-103 HCO3-32 AnGap-12 [2128-7-4] 02:13AM BLOOD Glucose-301* UreaN-9 Creat-0.5 Na-141 K-3.0* Cl-103 HCO3-28 AnGap-13 Pertinent Results: [2128-7-14] 05:40AM BLOOD WBC-6.6 RBC-3.21* Hgb-9.2* Hct-28.6* MCV-89 MCH-28.7 MCHC-32.2 RDW-18.8* Plt Ct-359 [2128-7-13] 05:25AM BLOOD WBC-6.8 RBC-3.38* Hgb-9.5* Hct-30.3* MCV-90 MCH-28.0 MCHC-31.2 RDW-17.0* Plt Ct-381 [2128-7-12] 02:17AM BLOOD WBC-6.9 RBC-3.03* Hgb-8.7* Hct-26.8* MCV-89 MCH-28.6 MCHC-32.3 RDW-16.6* Plt Ct-341 [2128-7-11] 02:09AM BLOOD WBC-7.7 RBC-3.15* Hgb-9.1* Hct-27.6* MCV-88 MCH-29.0 MCHC-33.0 RDW-17.1* Plt Ct-409 [2128-7-10] 04:39AM BLOOD WBC-7.6 RBC-2.80* Hgb-8.0* Hct-24.5* MCV-87 MCH-28.4 MCHC-32.5 RDW-17.1* Plt Ct-349 [2128-7-9] 01:54AM BLOOD WBC-7.2 RBC-3.08* Hgb-8.4* Hct-27.3* MCV-89 MCH-27.4 MCHC-30.9* RDW-15.5 Plt Ct-375 [2128-7-8] 02:03AM BLOOD WBC-6.7 RBC-2.98* Hgb-8.4* Hct-25.9* MCV-87 MCH-28.3 MCHC-32.5 RDW-15.4 Plt Ct-365 [2128-7-7] 02:55AM BLOOD WBC-10.9 RBC-3.24* Hgb-9.0* Hct-27.8* MCV-86 MCH-27.9 MCHC-32.5 RDW-16.5* Plt Ct-416 [2128-7-6] 02:53AM BLOOD WBC-11.6* RBC-3.41* Hgb-9.3* Hct-29.2* MCV-86 MCH-27.3 MCHC-31.8 RDW-15.1 Plt Ct-421 [2128-7-5] 04:55AM BLOOD WBC-15.7* RBC-3.91* Hgb-11.1* Hct-34.3* MCV-88 MCH-28.2 MCHC-32.2 RDW-15.3 Plt Ct-309 [2128-7-4] 02:13AM BLOOD WBC-14.8* RBC-4.09* Hgb-11.2* Hct-35.4* MCV-87 MCH-27.5 MCHC-31.8 RDW-14.8 Plt Ct-262 [2128-7-3] 06:06PM BLOOD WBC-16.6* [2128-7-3] 03:53AM BLOOD WBC-14.8* RBC-4.39 Hgb-12.1 Hct-37.7 MCV-86 MCH-27.7 MCHC-32.2 RDW-14.7 Plt Ct-275 [2128-7-2] 02:25AM BLOOD WBC-10.4 RBC-4.66 Hgb-12.8 Hct-40.0 MCV-86 MCH-27.4 MCHC-31.9 RDW-14.2 Plt Ct-207 [2128-7-1] 01:25AM BLOOD WBC-11.2* RBC-4.28 Hgb-12.0 Hct-37.2 MCV-87 MCH-28.0 MCHC-32.2 RDW-14.2 Plt Ct-138* [2128-6-30] 02:30AM BLOOD WBC-12.8* RBC-4.58 Hgb-12.6 Hct-38.7 MCV-85 MCH-27.5 MCHC-32.5 RDW-14.4 Plt Ct-168 [2128-6-29] 02:16AM BLOOD WBC-15.2* RBC-4.63 Hgb-13.0# Hct-38.4# MCV-83 MCH-28.0 MCHC-33.8 RDW-14.8 Plt Ct-153 [2128-6-28] 03:00AM BLOOD WBC-17.0* RBC-5.83* Hgb-16.2* Hct-49.1* MCV-84 MCH-27.7 MCHC-32.9 RDW-14.6 Plt Ct-188 [2128-7-14] 05:40AM BLOOD Glucose-107* UreaN-11 Creat-0.5 Na-146* K-3.8 [2128-7-13] 05:25AM BLOOD Glucose-112* UreaN-12 Creat-0.5 Na-145 K-3.9 Cl-106 [2128-7-12] 02:17AM BLOOD Glucose-157* UreaN-15 Creat-0.5 Na-144 K-3.7 Cl-106 HCO3-33* AnGap-9 [2128-7-11] 02:09AM BLOOD Glucose-146* UreaN-14 Creat-0.6 Na-142 K-4.3 Cl-104 HCO3-33* AnGap-9 [2128-7-10] 08:58PM BLOOD K-3.6 [2128-7-10] 04:39AM BLOOD Glucose-144* UreaN-15 Creat-0.5 Na-145 K-3.5 Cl-107 HCO3-31 AnGap-11 [2128-7-9] 01:54AM BLOOD Glucose-118* UreaN-12 Creat-0.5 Na-145 K-3.9 Cl-106 HCO3-33* AnGap-10 [2128-7-8] 02:03AM BLOOD Glucose-165* UreaN-10 Creat-0.6 Na-143 K-3.8 Cl-106 HCO3-31 AnGap-10 [2128-7-7] 02:55AM BLOOD Glucose-94 UreaN-9 Creat-0.6 Na-144 K-3.6 Cl-106 HCO3-29 AnGap-13 [2128-7-6] 06:59PM BLOOD K-4.0 [2128-7-6] 02:53AM BLOOD Glucose-164* UreaN-8 Creat-0.6 Na-143 K-3.8 Cl-105 HCO3-30 AnGap-12 [2128-7-5] 04:55AM BLOOD Glucose-178* UreaN-6 Creat-0.4 Na-143 K-3.6 Cl-103 HCO3-32 AnGap-12 [2128-7-4] 02:13AM BLOOD Glucose-301* UreaN-9 Creat-0.5 Na-141 K-3.0* Cl-103 HCO3-28 AnGap-13 Discharge Disposition: Extended Care Facility: [Hospital3 1174] [Hospital ] Hospital - [Location (un) ] [Name6 (MD) ] [Last Name (NamePattern4) 43] MD [MD Number(2) 44] Completed by:[2128-7-16]	[ "276.0", "493.90", "244.9", "427.31", "V10.3", "250.00", "434.91", "723.5", "276.9", "430", "331.4", "435.9", "272.0" ]	icd9cm	[ [ [] ] ]	[ "39.72", "96.72", "96.6", "02.39", "88.41", "96.04", "02.34" ]	icd9pcs	[ [ [] ] ]	16704, 16934	5485, 7086	393, 418	8113, 8137	13598, 16681	9861, 13579	667, 676		7145, 7925		8066, 8092		7112, 7122				8161, 9180	9206, 9838												706, 1000																										313, 355							446, 560	1293, 2024										1015, 1277						582, 626	642, 651				2045, 2085
56,476	107,869	6816	Discharge summary	report	Admission Date: [2199-11-4] Discharge Date: [2199-11-9] Service: MEDICINE Allergies: Morphine Attending:[Doctor First Name 2080] Chief Complaint: Biliary obstuction. Major Surgical or Invasive Procedure: ERCP IR guided biliary drain History of Present Illness: This is an 88 yo man transferred from OSH [11-4] for ERCP for biliary obstruction with obstructive hepatopathy. presented to [Hospital 1562] Hospital on [11-3] with increasing shortness of breath, dizziness, and jaundice. Per OSH also reported fevers, chills, and nausea. Had gveen given bactrim for a UTI one week prior. He underwent an abdomen CT which showed intrahepatic and extrahepatic obstruction likely secondary to metastatic cancer to the pancreatic head. He was started on flagyl, zosyn, and vanc and transferred to [Hospital1 18] for ERCP. While being prepped for ERCP (while under MAC) and turned prone he regurgitated coffee-brown material so he was electively intubated due to concern for his risk of aspiration. They proceded with ERCP, but were unable to cannulate the biliary tree. A dudodenal stent was placed due to external compression of the duodenum. He was placed on propofol for sedation and his SBP's dropped to the 80's in the PACU. He was started on neo through a PIV for pressure support. In the ICU the neo was rapidly weaned and he was extubated easily [11-5]. It was thought that his inability to extubate post-procedure and hypotension were due to sedation rather than aspiration given his rapid improvement. ROS: 10 point review of systems negative except as noted above. Past Medical History: 1. Colon cancer with mets s/p colectomy complicated with small and large bowel obstruction with a colostomy. Oncologist identified in OSH records as Dr. [Last Name (STitle) 25802]. 2. Prostate enlargement s/p TURP, ? in OSH of prostatic mets 3. Hypertension 4. Hypercholesterolemia 5. GERD 6. S/p tonsillectomy Social History: Lives alone. Per OSH records is a nonsmoker, and no alcohol use. Known family is sister in [Name (NI) 9012]. Family History: noncontributory Physical Exam: Vitals: Gen: well appearing, pleasant male HEENT: sclera icteric, PERRLA, EOMI, OP clear CV: +s1s2, rrr, no mrg appreciated Lungs: ctab Abd: + ostomy bag in place, + biliary drain in place, +bs, soft, nt, nd Ext: no c/c/e Pertinent Results: Admission labs: CBC:11.4 (n 89, no bands)->9.3, hct 25.1->28, plt 388 BMP: 135, 4.2, 102, 23, 19, 1.0, 94 alt 236->218, ast 300->268, ap 856->816, bili 11.8->11.2, lipase 184->120 ptt 28.4, inr 1.3 lactate 0.8 . Discharge Labs: [2199-11-9] 05:32AM BLOOD WBC-8.2 RBC-2.57* Hgb-8.3* Hct-25.8* MCV-101* MCH-32.3* MCHC-32.1 RDW-17.5* Plt Ct-383 [2199-11-9] 05:32AM BLOOD Glucose-102 UreaN-19 Creat-0.9 Na-139 K-3.5 Cl-106 HCO3-25 AnGap-12 [2199-11-9] 05:32AM BLOOD ALT-97* AST-58* AlkPhos-662* TotBili-5.4* . UA: BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-NEG PH-5.5 LEUK-MOD RBC-4* WBC-13* BACTERIA-FEW YEAST-NONE EPI-0 . Urine Cx [11-4]: no growth. Blood Cx [11-4]: pending. MRSA screen [11-4]: pending. . CXR port [11-4]: Lung volumes are quite low. With the chin down, the tip of the ET tube at the upper margin of the clavicles is 3 cm above optimal placement. [Month (only) 116] be left hilar enlargement and one or more nodules in the left lung. A band of atelectasis is present at the base of the right lung which is otherwise clear. Heart is mildly enlarged. No pneumothorax. Small bilateral pleural effusions, left greater than right, are likely present. An apparent bulge in the right mediastinal contour could be a skin fold instead. Repeat radiographs, conventional if possible, recommended when feasible. . ERCP [11-4]: A large amount of gastric fluid was found when the endoscope was passed into the stomach, suggestive of outflow tract obstruction. Unable to pass the scope to the second part of the duodenum due to obstruction, most likely extrinsic compression from colon cancer metastases. A duodenal stent ( 9cm x22mm Wallflex enteral duodenal stent) was placed successfully under fluoroscopic guidance to alleviate the gastric outlet obstruction. Ref 6502. Lot [Numeric Identifier 25803](stent placement) . Fluoro [11-6]: IMPRESSION: Percutaneous transhepatic cholangiogram demonstrating moderate intra- and extra-hepatic biliary ductal dilatation with obstruction of the common bile duct at the level of the ampulla. Successful placement of a right transhepatic internal-external biliary draining catheter with the catheter connected to a bag for external drainage Brief Hospital Course: Assessment and Plan: 88 yo male with pmh of metastatic colon cancer and hypertension who is being admitted to the [Hospital Unit Name 153] due to hypotension and need for continued intubation s/p ERCP attempt for biliary obstruction. . # Hypotension: Patient became hypotensive after intubation on propofol. Likely secondary to propofol, however also in the differential is hypotension from sepsis. He has two potential sources for sepsis: biliary obstruction and recent apsiration. Also could have volume depletion. Since coming to the floor his pressures had recovered and phenylephrine weaned off. Given the possibility of sepsis, he was started on vancomycin, flagyl and cefepime, but then changed to ceftriaxone and flagyl. The vancomycin was discontinued after the cultures were negative x 48 horus. On the day before discharge he was transitioned to PO levofloxacin to complete a full course through [11-11], cultures no growth to date at discharge. . # Biliary obstruction/obstructive jaundice: The patient underwent a CT at the OSH which showed intrahepatic and extrahepatic bile duct dilatation likely due to a metastasis to the pancreatic head from his colon cancer. He failed ERCP due to external compression of the duodenum limiting their ability to pass the scope. A duodenal stent was placed by the ERCP team to help to decompress the gastric outlet obstruction. Given the failed ERCP attempt, IR was consulted and performed an IR guided biliary drain on [2199-11-6]. He was transferred to the floor and his LFTs trended down after the stent was placed. His drain was clamped on [11-8] and with continued improvement of his liver tests and symptoms. He was discharged with a clamped biliary drain to follow up with interventional radiology. If symptoms return, the drain can be unclamped to a bag. . # Respiratory distress: The patient presented to the ICU intubated since the ERCP. On the following morning he was successfully extubated and breathing appropriately on room air. . # Anemia, chronic disease: The patient was noted to have coffe-ground regurgitation during the ERCP procdure. He was anemic with a Hct of 26 at the OSH and 25 on admission labs here. Vit B12 and folate normal at the OSH. Fe low, but other Fe studies not sent. Haptoglobin high makes hemolysis unlikely. Most likely due to anemia of chronic disease and possibly due to oncologic treatment. Started an IV PPI due to concern for coffee ground regurgitant. His hematocrits were stable and did not need transfusions. . # Metastatic colon cancer: Patient has multiple mets seen on OSH imaging. He will follow up with his outpatient surgeon after discharge. . # Hypertension, benign: stable Medications on Admission: Home medications: Prevacid 10 mg po daily Lipitor 10 mg po qhs Discharge Medications: 1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:2 Tablet(s) Refills:0 2. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Home With Service Facility: VNA of Upper [Hospital3 ] Discharge Diagnosis: Metatstatic colon cancer Gastric outlet obstruction s/p duodenal stent placement Biliary obstruction s/p IR placed drain Prostate enlargement s/p TURP Hypertension, benign Hypercholesterolemia gastroesophageal reflux Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital becuase you had an obstruction in the small bowel and also in your biliary tract. You went for a procedure that stented open your small bowel allowing you to eat liquids and solids. You then went to the have a drain placed in your biliary duct in order to the relieve the obstruction. Resume all of your home medications except Lipitor, until follow up with your doctors. You will need to continue the levofloxacin for 7 days until [2199-11-11]. You will need to follow up with your primary surgeon and your primary care doctor. Additionally, interventional radiology will contact you to follow up with your drain management. Return to the hospital if you experience fevers/chills, abdominal pain, recurring jaundice, or any other concerning symptoms. Followup Instructions: As above, you will need to follow up with your primary surgeon, Dr. [Last Name (STitle) 25804] when you return home, as well as with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 25237] as soon as possible. You will also need to follow up with the interventional radiology department in order to change the drain in 3 months. They will contact you to schedule this.	[ "V10.05", "578.9", "272.0", "537.0", "413.9", "507.0", "E938.3", "530.81", "576.2", "518.82", "401.1", "414.01", "285.22", "197.8", "458.29", "V44.3" ]	icd9cm	[ [ [] ] ]	[ "46.86", "45.13", "51.98" ]	icd9pcs	[ [ [] ] ]	7743, 7803	4672, 7378	237, 267	8064, 8073	2383, 2383	8918, 9312	2109, 2126		7492, 7720		7824, 8043		7404, 7404				8097, 8895					2611, 4649								2141, 2364				7422, 7469																						178, 199							295, 1625						2399, 2595											1647, 1963	1979, 2093
63,130	197,039	39280	Discharge summary	report	Admission Date: [2101-7-21] Discharge Date: [2101-8-15] Date of Birth: [2025-6-25] Sex: F Service: NEUROSURGERY Allergies: Penicillins Attending:[First Name3 (LF) 78] Chief Complaint: Sudden onset headache Major Surgical or Invasive Procedure: Angiogram x 2 Coiling of aneurysm placement of right frontal external ventricular drain History of Present Illness: Patient is a 76 yo Khmer speaking RHW with HTN, DM and hypercholesterolemia who developed sudden and severe HA around 10pm last night. Per daughter who lives with the patient, she was her usual self, watching television when she suddenly complained of severe headache and grabbed her daughter expressing her pain. She also complained of L sided chest pain. The daughter reports that patient had intact speech with comprehension and no asymmetry was noted. There was no hx of any falls or trauma. Ambulance was called and she was initially taken to [Hospital1 ] where she was found to be hypertensive to 220/83 but with normal EKG and CE's. Head CT showed extensive SAH - more L sided then R. Her pain appeared to be worse at [Hospital3 ] but she remained alert. She was given Nitro sublingual tablets 0.4mg x3 plus Zofran and she was transferred to [Hospital1 18] for further care. ROS negative per daughter and the patient is full code. She also has no prior hx of headaches. She does see her PCP [Name Initial (PRE) 30449] (every 2~3 months) and takes her meds but the daughter is unsure if her HTN is well controlled at baseline. Past Medical History: 1. HTN 2. DM 3. Hypercholesterolemia Social History: Social Hx: Originally from [Country ] and lives with daughter. Does not work and no smoking or EtOH hx. Full code per daughter/HCP, [Name (NI) ] [Telephone/Fax (1) 86893]. Family History: Parents hx unknown - no early deaths per Physical Exam: PHYSICAL EXAM: O: T: 98.5 BP:190/98 HR: 70 R: 15 O2Sats: 100% RA Gen: Appears uncomfortable and complains of frontal HA in Khmer. Neck: Stiff. Lungs: Clear. Cardiac: RRR. No M/R/G appreciated.. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person and hospital. Language: Speech fluent with good comprehension per daughter. Cranial Nerves: I: Not tested II: L pupil larger than R (3L and 2R) but both reactive. Blinks to visual threat bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. No pronator drift. Unable to do individual muscle group testing but appears full including biceps/triceps, and no drift with either IPs. Sensation: Intact to light touch and cold. Reflexes: B T Br Pa Ac Right 2 1 2 2 1 Left 2 1 2 2 1 Toes downgoing bilaterally ****ON DISCHARGE Awake and Alert Responds to question in native tongue and is able to follow complex commands. Left Pupil 7mm and non reactive CN 3 and 6 palsy on the left Motor exam full Pertinent Results: Cardiology Report ECG Study Date of [2101-7-21] 1:38:18 AM Sinus rhythm. Left atrial abnormality. A-V conduction delay. Q-T interval prolongation. No previous tracing available for comparison. Read by: [Last Name (LF) 578],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 579] Intervals Axes Rate PR QRS QT/QTc P QRS T 68 210 82 466/480 48 20 64 ////////////////////////////////////////////////////////// Radiology Report CTA HEAD W&W/O C & RECONS Study Date of [2101-7-21] 2:32 AM Final Report CLINICAL HISTORY: Subarachnoid hemorrhage, OSH. Evaluate aneurysm. TECHNIQUE: CT HEAD: CTA head and neck with sagittal and coronal reconstruction, volume rendering over the right and left anterior and posterior circulation with curved measurements and COW tumble and rotation images. FINDINGS: CT HEAD: There is extensive subarachnoid hemorrhage in the basal cisterns and left cerebral sulci and extending into the interhemispheric fissures with intraventricular extension as evidenced by layering of [Date Range ] in the posterior horns of both lateral ventricles. There is generalized sulcal effacement and cerebral edema. No intraparenchymal hematoma is shown. There is slight prominence of both temporal horns suggestive of early hydrocephalus. Small lacunar infarcts are seen in the basal ganglia. CTA NECK: There is calcification in the aortic arch. The origin of the arch vessel is normal. Both cervical carotid arteries are tortuous. There is atheromatous plaque with minor calcification at the carotid bifurcation on the right. The luminal diameter of the distal right ICA is 4 mm compared to proximal luminal diameter of 6 mm. There is atheromatous calcification of the carotid bifurcation on the left with calcification. The luminal diameter of the distal left ICA is 5 mm compared to the proximal ICA diameter of 4 mm. POSTERIOR CIRCULATION: Tha basilar artery is thin. Both vertebral arteries show opacification. The right vertebral artery origin is identified, but the left vertebral artery origin is poorly identified on this study. CTA HEAD: Two small aneurysms are seen at the junction of left PCA and posterior communicating artery. The larger aneurysm measuring 4 mm x 3 mm in the axial plane is superiorly and laterally directed and the smaller 3 x 3 mm aneurysm is medially directed. There is calcification of both carotid siphons. IMPRESSION: Extensive subarachnoid hemorrhage and extension into the posterior [Doctor Last Name 534] of both lateral ventricles. Two small aneurysms identified at the junction of left posterior communicating artery and posterior cerebral artery as described above. Atheromatous disease of both cervical carotid arteries and hypoplastic origin of the left vertebral artery. / / / //////////////////////////////////////////////////////////////// Radiology Report [Numeric Identifier 70158] EMBO TRANSCRANIAL Study Date of [2101-7-21] 12:39 PM Final Report CLINICAL INDICATION: 76-year-old woman with subarachnoid hemorrhage. CT angiography demonstrated two aneurysms in the left PCOM. DOCTORS: Dr. [First Name (STitle) ].[Doctor Last Name ] and Dr. [First Name8 (NamePattern2) 13361] [Name (STitle) 13362]. The attendings Dr.[Last Name (STitle) ] and Dr [First Name (STitle) ] performed the procedure. ANESTHESIA:Anesthesia team performed the general anesthesia and the patient was intubated. PROCEDURE: After explaining the risks, benefits and the alternatives for the procedure, a informed written consent was obtained. The patient was brought to the angiography suite and placed supine on the table. A usual timeout and huddle was performed as per [Hospital1 18] protocol. The right groin was prepped and draped in the usual sterile fashion. The right CFA was access was obtained and a 6 French sheath was placed.The side arm connected to the heparin flush system. A 4 French Berenstein catheter was then used to navigate into the right common carotid, angiogram performed to demonstrate CCA bifurcation. Under road map the ICA was cannulated and angiogram was performed with images acquired in AP and lateral views and 3D view. Findings: 1.mild irregularities and narrowing seen in a.distal segment of the petrous part of the ICA b.supraclinoid portion of the ICA. c. right PCOM d.proximal portion of the temporoparietal branch of the MCA also demonstrated irregular narrowing. 2.Good collateral flow across the ACOM is noted. The other MCA and the ACA branches show normal caliber and filling. There is good capillary blush and venous filling noted with no evidence of vascular malformations, aneurysms, or venous occlusions. 3.A small shelf-like plaque is seen in the distal cervical segment of the ICA. Next, the left common carotid artery was cannulated and a diagnostic angiogram performed. Findings: 1.Ulcerative plaque measuring about 1 cm in length seen in the proximal ICA on the posterior wall. 2.Mild areas of irregularity are noted in the horizontal portion of the left ICA. 3.The ophthalmic branch of the ICA fills well and a good retinal blush is noted. Normal bifurcation of the internal carotid artery is noted. 4.Multiple areas of vascular narrowing are noted in the branches of the MCA, especially in the temporoparietal and the posterior angular branches. Areas of narrowing are noted in the distal aspect of the left posterior communicating artery. 5.Two,3 mm [Doctor Last Name ] aneurysms from the distal aspect of the posterior communicating artery approximately 1 cm from the ICA bifurcation are seen. The distally located aneurysm is directed postero-laterally and the other proximal aneurysm is directed inferiorly and medially. The proximal aneurysm demonstrates a narrow neck, while the distal aneurysm lacks a neck. There is no evidence of other aneurysms, or vascular formations.No obvious teat sign noted. 5.Optimal filling in the left posterior cerebral artery is seen. Good capillary filling and venous filling with antegrade venous filling is noted. No evidence of venous occlusions or dural AV fistula is seen. Both the internal jugular veins fill well. A left subclavian artery angiogram was performed which did not demonstrate the left vertebral artery and was likely non-dominant/occluded. A right subclavian arterial angiogram revealed narrowing at the origin of the vertebral artery which was therefore not cannulated. A [Doctor Last Name ] pressure cuff was applied to the right upper arm which was inflated and a right subclavian arterial angiogram was performed to fill the right vertebral artery which showed normal course and caliber. The basilar artery and its branches are normal. Next a 5 French [Doctor Last Name ] catheter was used to cannulate the left common carotid artery over a 0.035 angled Glidewire. A 6F Neuron catheter was navigated into the left internal carotid artery. A diagnostic angiogram was performed from this location through the Neuron catheter to best demonstrate the two aneurysms in an oblique projection. A coaxial system using a Echelon straight microcatheter was navigated through the Neuron catheter over a Xpeedior wire into the left PCOM. The tip of the catheter was placed at the neck of the proximal aneurysm and one 2.5 x 3.3 microsphere coil was placed and detached followed by two 2 x 4 GDC Soft Coils that were deployed and detached. Intermittent check angiograms were performed to delineate the flow and coil position. Gradual filling of the second aneurysm was performed using two, 2 x 2 UltraSoft GDC Coils were deployed in the distal aneurysm. Followup check angiogram revealed good flow in the PCOM and the posterior cerebral artery with no areas of occlusion or contrast extravasation. There was stagnation of flow in the distal aneurysm with no flow detected in the proximal aneurysm sac. The microcatheter was then removed over the wire. Diagnostic angiogram was performed to the Neuron catheter which revealed good occlusion and stagnation of flow in the aneurysm sacs. At this time a decision was made to stop further intervention. The Neuron catheter was then removed. The 6 French sheath was then exchanged for a short 6 French sheath in the common femoral artery which was connected to a heparin flush. The patient's hemodynamic status was monitored throughout the procedure. No major complications were noted. IMPRESSION: Three-vessel cerebral angiogram was performed at the right internal carotid artery, right vertebral artery and the left common carotid artery. FINDINGS: 1. Irregular areas of narrowing are noted in the distal part of the petrous segment of the right ICA, the right PCOM and the temporoparietal branches of the right middle cerebral artery. 2. A large ulcerative plaque is noted in the posterior wall of the proximal left internal carotid artery. 3. Multiple areas of narrowing are noted in the temporoparietal and posterior angular branches of the left MCA and also in the left PCOM . 4. Two [Doctor Last Name ] aneurysms are noted from the distal segment(1 cm) of the left PCOM, one directed inferior medially and other directed posterior laterally. 5. Successful coiling of the aneurysms were performed using GDC coils through the left ICA approach. There was no evidence of contrast extravasation, vascular occlusions following the procedure. The presence of multiple skip areas of arterial irregularities and narrowing are concerning for vasculitis for which a further workup may be recommended.Atherosclerotic involvement is another differential to be considered. ////////////////////////////////////////////////////////// Radiology Report CT ABDOMEN W/O CONTRAST Study Date of [2101-7-21] 5:47 PM Final Report FINDINGS: NON-CONTRAST CT OF THE ABDOMEN: There is bibasilar atelectasis. The heart size is enlarged. The unenhanced liver, spleen, pancreas, and adrenal glands are normal. There is high-density material layering within the gallbladder which likely represents excreted contrast from previous intravenous contrast administration. There is a 0.7 cm hypodensity within the upper pole of the left kidney along with 0.5 cm hypodensity within the lower pole of the left kidney, lesions which are too small to characterize but likely represent cysts. There is no hydronephrosis. There is no abnormal lymphadenopathy in the abdomen. There are multifocal areas of calcified atherosclerotic plaque in the abdominal aorta. There is no aneurysmal dilatation of the aorta. There is no free fluid or free air identified. Loops of bowel in the abdomen are normal in course and caliber. NON-CONTRAST CT OF THE PELVIS: There is a Foley catheter in the bladder along with residual contrast in the bladder and bilateral collecting systems. There are small uterine fibroids present. There is no free fluid or abnormal lymphadenopathy in the pelvis. There is a right femoral vascular catheter in place. There is no retroperitoneal hematoma identified. The bowel loops in the pelvis are normal in appearance. OSSEOUS STRUCTURES: There are multilevel degenerative changes of the lumbar spine, most advanced at the L5-S1 with grade 1 anterolisthesis along with bilateral spondylolysis. There are no lytic or blastic lesions identified. IMPRESSION: 1. No evidence of retroperitoneal hematoma as questioned. 2. Grade 1 anterolisthesis of L5 on S1 with bilateral spondylolysis. /////////////////////////////////////////////////////////// Radiology Report CT HEAD W/O CONTRAST Study Date of [2101-7-21] 6:09 PM Final Report INDICATION: 76-year-old female with subarachnoid hemorrhage status post coiling. Evaluate for interval change. COMPARISON: CTA head [2101-7-21] at 3:08 a.m. and CT head of [2101-7-21] at 8:20 a.m. TECHNIQUE: Contiguous axial images were obtained through the brain without IV contrast. Please note that the patient underwent cerebral angiogram six hours earlier. FINDINGS: There has been interval placement of a ventriculostomy catheter which terminates in the third ventricle from a right frontal approach. The ventricular size is essentially unchanged from prior. Streak artifact from new metallic coils is noted in the region of the left posterior communicating artery. There is a large amount of new hyperdense material along the cerebral falx, measuring up to 6 mm in greatest width, consistent with extra-axial hemorrhage. A small amount of hyperdense material is also noted along the inferior left frontal lobe consistent with subdural hematoma. There is increased conspicuity of hyperdense material in the left cerebral and right parieto-occipital sulci, likely representing interval evolution of [Year (4 digits) ] products; however, small foci of new subarachnoid hemorrhage cannot be entirely excluded given recent administration of IV contrast. A serpiginous hyperdense focus in the right superior temporal lobe (2:11) is also more apparent than on the prior study and could represent an enhancing [Year (4 digits) ] vessel versus new or evolving focus of subarachnoid hemorrhage. [Year (4 digits) ] products in the basilar cisterns and layering in the bilateral occipital horns are similar to prior. Globes and lenses are intact. Visualized paranasal sinuses are well aerated. IMPRESSION: 1. Interval placement of a ventriculostomy catheter from a right frontal approach terminating in the third ventricle. No significant change in ventricular size. 2. New hyperdense collection along the cerebral falx and left inferior frontal lobe most likely represents subdural hematoma. 3. Evaluation for new small foci of hemorrhage is limited by recent administration of IV contrast. Within this limitation, increased conspicuity of a serpiginous hyperdensity in the right temporal lobe could indicate a new or evolving focus of hemorrhage but enhancing vessel is also possible. Interval evolution of multiple foci of subarachnoid hemorrhage in the left cerebrum and right parieto-occipital lobes. Close interval followup is recommended. ////////////////////////////////////////////////////// [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 86894]Portable TTE (Complete) Done [2101-7-22*] at 10:51:59 AM FINAL Results Measurements Normal Range Left Atrium - Long Axis Dimension: 2.8 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.1 cm <= 5.2 cm Right Atrium - Four Chamber Length: 4.2 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: 3.8 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 1.7 cm Left Ventricle - Fractional Shortening: 0.55 >= 0.29 Left Ventricle - Ejection Fraction: 70% >= 55% Left Ventricle - Lateral Peak E': 0.05 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.04 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 13 < 15 Aorta - Sinus Level: 2.6 cm <= 3.6 cm Aorta - Ascending: 3.3 cm <= 3.4 cm Aorta - Arch: 2.4 cm <= 3.0 cm Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec Aortic Valve - LVOT diam: 1.7 cm Mitral Valve - E Wave: 0.6 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A ratio: 0.86 Mitral Valve - E Wave deceleration time: 293 ms 140-250 ms TR Gradient (+ RA = PASP): 15 mm Hg <= 25 mm Hg Pulmonic Valve - Peak Velocity: 0.8 m/sec <= 1.5 m/sec Findings LEFT ATRIUM: Normal LA size. LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Normal aortic arch diameter. Focal calcifications in aortic arch. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Trivial MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid valve supporting structures. No TS. Mild [1+] TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. Conclusions The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%). Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. 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. //////////////////////////////////////////////////// Radiology Report CT BRAIN PERFUSION Study Date of [2101-7-25] 8:18 AM Final Report INDICATION: 76-year-old woman with PCA/PCom aneurysm. Please evaluate for vasospasm and hydrocephalus as patient has increased lethargy. TECHNIQUE: Contiguous axial images obtained through the brain without contrast material. An axial perfusion CT run was performed during the infusion of IV contrast. Subsequently rapid axial imaging was performed through the brain during infusion of IV contrast material. Images were processed on a separate workstation with display of mean transit time, relative cerebral [Name2 (NI) ] volume and cerebral [Name2 (NI) ] flow maps for the CT perfusion study and curved reformats, volume-rendered images and maximum intensity projection images for the CTA. COMPARISON: Comparison is made to CTA performed [2101-7-21]. FINDINGS: HEAD CT: There are small hemorrhagic changes along the tract of the prior right external ventricular drain with stable associated pneumocephalus. There is no evidence of new edema, mass effect, or infarction. The ventricles are stable in size with slightly increased [Year (4 digits) ] layering in the bilateral occipital horns of the lateral ventricles likely due to redistribution of [Year (4 digits) ] products. The subarachnoid hemorrhage seen on prior study layering along the left cerebral sulci is less visible possibly due to increased isodensity of [Year (4 digits) ] products representing evolution. The basilar cisterns are patent. CT PERFUSION: The perfusion maps appear normal with no evidence of delayed transit time or reduced [Year (4 digits) ] flow or [Year (4 digits) ] volume. Incidentally, of unclear clinical significance, there is a decreased mean transit time in the left posterior cerebral circulation affecting the median occipital and parietal lobes. HEAD CTA: There is no evidence of new stenosis. IMPRESSION: Slightly ncreased hemorrhagic changes along tract of prior right EVD. Ventricle size stable with redistribution of [Year (4 digits) ] products. No suggestion of infarct or ischemia. Decreased MTT in left posterior cerebral circulation. No vasospasm, new aneurysm, or stenosis. /////////////////////////////////////////////////////////////// Radiology Report CT BRAIN PERFUSION Study Date of [2101-7-29] 5:40 PM Final Report EXAM: CTA of the head and CT perfusion head. CLINICAL INFORMATION: Patient with status post embolization of the left posterior cerebral artery aneurysms, for further evaluation to exclude vasospasm. TECHNIQUE: Axial images of the head were obtained without contrast. Following this, using departmental protocol, CT angiography and CT perfusion of the head were acquired. FINDINGS: CT HEAD: Comparison was made with the previous study of [2101-7-25]. There has been evolution of the [Year (4 digits) ] products. Subarachnoid hemorrhage still identified. The [Year (4 digits) ] products at the site of the ventricular drain have decreased. There are chronic infarcts in the basal ganglia as before. Artifacts from the embolization are seen in the left perimesencephalic region. CT PERFUSION HEAD: CT perfusion of the head again demonstrates slightly increased mean transit time in the right posterior cerebral artery region without decrease of [Year (4 digits) ] volume. This is unchanged from previous study. No other perfusion abnormalities are seen. CT ANGIOGRAPHY OF THE HEAD: The CT angiography of the head demonstrates no change in appearance of the vascular structures in anterior and posterior circulation. There is no change in caliber of the vascular structures to indicate acute vasospasm since the previous study. IMPRESSION: 1. Evolution of [Year (4 digits) ] products since the previous study with subarachnoid hemorrhage is still identified. No acute hydrocephalus seen. Other findings as described above. 2. CT perfusion demonstrates slightly increased mean transit time in the right posterior circulation as before. 3. CT angiography of the head demonstrates no evidence of change in caliber of the vascular structures in the anterior and posterior circulation to indicate occlusive vasospasm. ////////////////////////////////////////////////////////////// Radiology Report BILAT LOWER EXT VEINS Study Date of [2101-8-1] 10:18 AM Final Report HISTORY: A 76-year-old female with subarachnoid hemorrhage status post coiling, now with fever, evaluate for DVT. COMPARISON: None available. BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: The common femoral veins, superficial femoral veins, deep femoral veins, greater saphenous veins, and popliteal veins demonstrate normal color flow, respiratory phasicity, and normal waveforms and appropriate responses to augmentation and Valsalva maneuvers. The calf veins also demonstrate normal color flow. IMPRESSION: There is no evidence of DVT. ///////////////////////////////////////////////////////////// CTA/P [2101-8-3] 1. Persistent large amount of subarachnoid hemorrhage along the left cerebral convexity with some redistribution to the contralateral side, with similar amount of [Month/Day/Year ] layering in the lateral ventricular atria and occipital horns. 2. Congenitally hypoplastic posterior circulation significantly limits its evaluation for vasospasm, but the principal vessels remain patent. Patent and stable caliber anterior circulation, with increased number and size of distal MCA and ACA branches, perhaps related to interval vasodilator therapy, but no evidence for vasospasm. 3. No focal perfusion abnormality. 4. Focal stenosis, mid-V4 segment of left vertebral artery, unchanged. ///////////////////////////////////////////////////////////// [8-7] EEG: IMPRESSION: This is a mildly abnormal VEEGtelemetry recording due to the presence of occasional bursts of diffuse delta slowing. This is suggestive of a mild diffuse encephalopathy, such as from medication effect, metabolic derangement or infection. The beta activity seen throughout is consistent with medication effect, most commonly benzodiazepines or barbiturates. No clear evidence of epileptiform activity was observed. /////////////////////////////////////////////////////////// [8-12] CT head: 1. Interval near complete resolution of subarachnoid and intraventricular hemorrhages with no evidence of new hemorrhage. 2. Lacunar infarcts in the bilateral basal ganglia is unchanged from prior study. 3. Mild dilatation of the temporal horns of the lateral ventricles, unchanged from prior study. Brief Hospital Course: This patient presented to the ED after sudden onset headache. Imaging in the emergency department showed SAH with ? PCOMM aneurysm. She was admitted to the neurosurgery service ICU monitoring. Early am that same day [7-21] she was noted to be more lethargic with asymmetric pupils and a new right pronator drift. She also had difficulty participating with the exam. A CT was obtained which was grossly unchanged from the previous scan however it was felt that the patients exam warrented placement of external ventricular drain. As planned she underwent a cerebral angiogram on hospital day 1 with successful coiling of left PCOMM and PCA aneurysms. During the angiogram it was noted that her hemtocrit dropped to 26 and she was acidotic with an elevated lactate. She received II units PRBC's and was kept intubated till the following am. A post angio CT abdomen confirmed that there was no retroperitoneal hemorrhage. The femoral sheath was removed the post procedure day 1. Throughout the hospitalization her exam did fluctuate. She has also developed a third nerve palsy on the left for which she was seen by ophto for. Her family was available at all times to translate and assist with the exams. CTA/P was done on [2101-7-25] which did not demonstrate vasospasm. Her follow up angiogram was completed on the [2101-7-28] and she was found to be in mild vasospasm and was given intra-arterial verapamil. She was autoregulating her BP and we were treating only if it dropped less than 180. She did recieve hydralazine intermittently for BP > 220. Her exam continued to flucutate but overall was improved. She underwent a third angiogram on [2101-8-1] which she again showed mild vasospasm and was treated with verapamil. We were again treating BP only for <180 or >220. Her post procedural hct dropped to 26 and serial hcts were followed. She was transfused with 2 units fo PRBC's on [8-2] for her hct which dropped as low as 23.2 which after the 2 units of red cells rose to 28.3. Without further intervention her hct raised to 33.4 on the afternoon of [8-3]. Following her drop in crit after the angiogram a CT of the abdomen and pelvis with and withotu contrast was obtained to rule out retroperitoneal bleed. The CT showed no extravasation of contrast but it did show a right perinephrenic hematoma. On the angiogram on [8-1] there remained the question of vasculitis and ESR and CRP were further elevated. Stroke neurology felt that vasculitis was unlikely and that the steroids could be stopped. They felt her ESR CRP were elevated simply by the SAH alone. On [8-3] she was lethargic on exam and as a result a CTA/P was ordered which was normal. She also had a urine culture which was positive for e-coli and cipro was initially started to treat this. On [8-4] her antibiotic regimen was changed to meropenem x 10 days for treatment of the UTI after sensitivites returned. Her exam also improved on [8-4] as she was more alert and cooperative. On [8-5] she continued to be stable in the ICU and her [Month/Year (2) ] pressure parameter were liberalized to only treat SBP <140 and >160. there was concern for a perinephric hematoma on Ct scan which was done following her second cerebral angiogram. Interventional radiology discussed the need for diagnostic renal angiogram to evalaute in the setting of decreasing hematocrit over the prior days. Ultimately it was decided that this would not be required and that her hematocrit should be monitored. Over the course of the weekend of [8-6] and [8-7] her exam remained stable and she had no complications or events also her hematocrits were 29.8 and 31.6 respectively. On [8-8] she continued to be stable and on the morning of [8-9] she was deemed appropriate to be transferred to the step down unit. On [8-12] while getting out of bed with Physical therapy patient's [Month/Year (2) ] pressures were noted to be in the 200s and she was complaining of chest pain, although her chest pain seemed to be more pleuritic. EKG was stable in comparison to a perevious, Cardiac enzymes were flat and the CXR was unremarkable. We initiated some IV and PO antihypertensive therapy. A CT of the head was also performed secondary to stated confusion by her daughter and read as stable. On [8-15] completed a ten day course of Meropenum for VRE in the urine and her PICC line was removed. Upon evaluation by Physicial Therapy patient seems to be appropriate for discharge home with 24 hour supervision that her family will be to provide. Medications on Admission: Medications prior to admission: 1. Lisinopril 40mg daily 2. Metformin 500mg [Hospital1 ] 3. Glyburide 10mg daily 4. Tylenol 500mg PRN for pain 5. Cyproheptadine 4mg daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:30 Tablet(s) Refills:0 2. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 4. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic QID (4 times a day) as needed for dry eye. Disp:qs 30ml Refills:0 Discharge Disposition: Home With Service Facility: All Care VNA and Hospice - [Hospital1 189] Discharge Diagnosis: Subarachnoid hemorrhage - ruptured aneurysm cerebral aneurysm Left Posterior Communicating Artery cerebral aneurysm Posterior Communicating Atery Aneurysm Cranial nerve three deficit on Left left ptosis VRE Obstructive hydrocephalus cerebral vasospasm urinary tract infection right perinephrenic hematoma/ spontaneous post procedure anemia requiring transfusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Angiogram with Embolization 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. Followup Instructions: Please follow up with Dr [First Name (STitle) ] in..... call [Telephone/Fax (1) 1669] for appt YOU NEED TO SEE YOUR PRIMARY CARE PHYSICIAN WITHIN TWO WEEKS OF DISCHARGE AND UPDATE HIM/HER REGARDING YOUR HOSPITALIZATION YOU NEED TO CALL [Telephone/Fax (1) ] TO FOLLOW UP WITH THE OPTHOMOLOGY (EYE DOCTORS) DEPARTMENT Completed by:[2101-8-15]	[ "276.2", "430", "593.81", "378.51", "041.4", "374.30", "331.4", "272.0", "435.8", "401.9", "250.00", "041.04", "V09.80", "285.1", "599.0" ]	icd9cm	[ [ [] ] ]	[ "38.91", "88.44", "88.41", "39.72", "38.93", "02.39" ]	icd9pcs	[ [ [] ] ]	32327, 32404	27084, 31673	296, 386	32810, 32810	3293, 3906	33281, 33642	1852, 1894		31899, 32304		32425, 32789		31699, 31699				32961, 33258													1924, 2167											31731, 31876															235, 258							414, 1574	2362, 3273		26757, 27061		21377, 23250						32825, 32937						1596, 1634	1650, 1836
20,486	166,724	53085	Discharge summary	report	Admission Date: [2118-7-7] Discharge Date: [2118-7-12] Date of Birth: [2051-2-2] Sex: F Service: MEDICINE Allergies: Levaquin / Bactrim / Flexeril / Codeine Attending:[First Name3 (LF) 4232] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: BIPAP History of Present Illness: The patient is a 67 year old female with a history of CREST/scleroderma, COPD (known to Dr. [First Name4 (NamePattern1) 4648] [Last Name (NamePattern1) ], FEV1% 62%), mild PAH (echo [5-29] PAH 27 mm Hg), no known CAD, bilateral diffuse peripheral vascular disease who presented to the ED from her PCP's office on [2118-7-7] the chief complaint of worsening shortness of breath. . The patient has a long history of exertional dyspnea with mild PAH and says she is short of breath with exertion at baseline but is able to walk 2 blocks without difficulty at baseline. However, over the past 1-2 weeks, the patient notes that she has had progressive increasing shortness of breath that manifested on the Sunday prior to admission when she was walking to her car (approximately 600 feet) and felt increased shortness of breath, diaphoresis, no chest pain or radiating pain to her jaw/back/arms. She experiences bilateral calf pain with a history of bilateral PVD with exertion and thought she was anxious because of the pain. . Of note, she recently returned from [Country 4754] [6-14] to [2118-6-21]. Her symptoms began shortly thereafter. . The patient has noticed increasing orthopnea requiring 2 pillows over the past week (she sleeps without a pillow at baseline). Her weight she thinks has been stable. She admits to paroxysmal nocturnal dyspnea which she says is new after prolonged coughing spells (sparse white sputum) with lying flat. She denies any chest pain or radiating symptoms. She admits to a salty diet and drinks at least 60 oz. of fluid a day. She states her baseline weight is 153 pounds. . She saw her NP at [Hospital3 4262] Group on Monday. She was given 2 nebulizer treatments and sent home with albuterol and atrovent for presumed COPD exacerbation. She has never been intubated before and does not have a peak flow meter at home. Her symptoms did improve with nebulizers. . She was re-evaluated on Wednesday by her NP who then treated her again with 2 albuterol/atrovent nebulizer treatments and gave her azithromycin 500 mg for which she took 2 doses. . She was to follow up on [2118-7-7] in clinic but called early given increasing shortness of breath. She was evaluated in the clinic and referred to the ED for further management. Labs from her PCP's office on [7-6] revealed a sodium of 127, HCO3 22. Hct 35. . In the ED, she was given 125 mg IV solumedrol for ? COPD exacerbation. Her CXR was negative for acute disease/CHF. Her EKG had no ischemic changes. However, her CK was 296, MB 27, MBI 9.1, trop 0.1 (new). BNP 3698 ( up from 98 in [May 2117]). Her Na was 119 (she has reported history of hyponatremia). She was given ASA 325 mg and albuterol nebulizer. Initially, she was breathing on 2 liters O2 sat'ing in the mid 90s and was 92% on RA. She underwent a a CT-A to rule out PE and upon her return, she became acutely diaphoretic, tachypneic to the 40s and her SBP peaked to the 220s -> she was placed on CPAP+ PS TV FiO2 100%, TV 911, rate 27, PEEP 5, PSV 5, sat'ing 96% and a nitro gtt. . Her EKG showed sinus rhythm at 98 bpm, NL axis, intervals. Delayed R wave progression. Flattened T waves I, AVL, V1-V2. No STE/depression. Compared to baseline [5-29], no change. . A gas during this time showed on BIPAP: . 7.17/54/369/21 . Cardiology was consulted in the ED given her elevated cardiac enzymes but felt her presentation was noncardiac and not ischemic in origin. She was started on a heparin gtt in the ED. . In the ED, the patient had a CT-A on [2118-7-7] which showed no PE. A CXR showed no CHF. . On arrival to the MICU, the patient was 93% on RA and 97% on 4 liters O2, breathing comfortably off of CPAP which she stated she had been on for 45 minutes. . ECHO [2117-6-7]: . Conclusions: EF >55%, diastolic dysfunction. Mild PAH, 27 mm Hg. . The patient had a similar presentation in [5-29] at which time she ruled out for an MI, found to not have a PE, and her symptoms were felt to be secondary to a URI. . ROS: . Positive for claudication. No fevers/chills. Positive for cough worse with lying flat. Recent constipation relieved with laxatives. . Past Medical History: * Carotid artery disease, 40-59% right carotid stenosis. Less than 40% left * COPD, followed by Dr. [First Name4 (NamePattern1) 4648] [Last Name (NamePattern1) ]: FEV1 62% of predicted with a FEV1/FVC ratio of 71% of predicted; consistent with mild to moderate obstruction felt due to prior smoking history. * HTN * Osteoporosis * PVD, diffuse bilateral on pletal - followed by Dr. [Last Name (STitle) ] * Barrett's esophagus, GERD * CREST - sees rheum at [Hospital1 2177], [Hospital1 18] * History of hyponatremia * Colonic adenoma - [8-27], Dr. [Last Name (STitle) 2987] * Endometriosis . Past Surgical History: . Hysterectomy Social History: Currently lives alone. Previously worked as administrator at [Company 25186], now on disability. Tob: 0.5ppd x 45years but quit in [2115-10-25]. Previous exposure to asbestos in past. EtOH: occasional. Family History: Mother: Scleroderma, deceased from CHF at 67 Father: no medical problems, deceased at 98 Sister: [Name (NI) 25670] with scleroderma, deceased at age of 25 from congenital heart disease Brother: deceased from MI at 53 Brother: colon cancer Physical Exam: Tc = 96 P = 96 BP = 147/73 RR= 17 O2 sat= 97% on 4 liters NC Wt. 73 kg . Gen - NAD, breathing comfortably, no accessory respiratory muscle use HEENT - PERLA, EOMI, anicteric, atraumatic, up to 11 cm JVD with expiration Heart - RRR, no M/R/G Lungs - CTAB, no wheezes/crackles Abdomen - Soft, NT, ND, + BS, no hepatosplenomegaly Ext - trace bilateral lower extremity edema, L mildly > R, +1 d.pedis bilaterally, +1 p.t. RLE, BUE wrist, PIP swollen erythematous, thickened skin, radial deviation at MCP joints Skin - Hypermelanotic 1 mm symmetric mole on RLE medial calf Neuro - CN II-XII grossly intact . Pertinent Results: LABS ON ADMISSION: [2118-7-7] 12:35PM WBC-9.0 RBC-3.91* HGB-13.4 HCT-36.2 MCV-93 MCH-34.2* MCHC-36.9* RDW-13.7 [2118-7-7] 12:35PM NEUTS-78.4* LYMPHS-14.2* MONOS-4.1 EOS-3.0 BASOS-0.3 [2118-7-7] 12:35PM PLT COUNT-327 [2118-7-7] 12:35PM PT-12.2 PTT-26.4 INR(PT)-1.0 [2118-7-7] 12:35PM cTropnT-0.10* [2118-7-7] 12:35PM CK-MB-27* MB INDX-9.1* proBNP-3698* [2118-7-7] 12:35PM GLUCOSE-98 UREA N-10 CREAT-0.6 SODIUM-119* POTASSIUM-4.7 CHLORIDE-86* TOTAL CO2-20* ANION GAP-18 [2118-7-7] 12:54PM LACTATE-1.0 [2118-7-7] 04:02PM TYPE-ART PO2-369* PCO2-54* PH-7.17* TOTAL CO2-21 BASE XS--9 [2118-7-7] 05:22PM cTropnT-0.10* [2118-7-7] 05:22PM CK-MB-32* MB INDX-10.4* [2118-7-7] 05:22PM CK(CPK)-308* [2118-7-7] 08:44PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.050* [2118-7-7] 08:44PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2118-7-7] 08:44PM URINE RBC-[3-28]* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 EKG [2118-7-7]: sinus rhythm at 98 bpm, NL axis, intervals. Delayed R wave progression. Flattened T waves I, AVL, V1-V2. No STE/depression. Compared to baseline [5-29], no change. CXR [2118-7-7]: no CHF. CT-A [2118-7-7]: No PE. FINDINGS: No filling defect is identified within the pulmonary arteries. No focal consolidation or pleural effusion is identified. The heart is normal in size. The proximal coronary arteries are patent. The pericardium is unremarkable. Again noted are bullous changes, more prominent at the apices, consistent with emphysema, unchanged. Previously described small non- calcified nodules in the right middle lobe (series 2, image 36), right upper lobe (series 2, image 19) and left upper lobe (series 2, image 10) are unchanged. Pleural plaques are present which is consistent with prior asbestos exposure. No pathologically enlarged mediastinal or axillary lymph nodes are identified. Atherosclerotic disease is again noted throughout the aorta with evidence of ulcerative plaques. Limited views of the upper abdomen demonstrate prominence of the left adrenal gland noted before. Small hiatal hernia is present. Note is made of somewhat dilated esophagus with air fluid level. BONE WINDOWS: No suspicious lytic or sclerotic lesion is identified. IMPRESSION: 1) No evidence of pulmonary embolus. Again seen is extensive emphysematous changes not significantly changed from prior study. ECHO [2118-7-8] - The left atrium is normal in size. The estimated right atrial pressure is 5-10 mmHg. 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 valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. IMPRESSION: Normal biventricular cavity size and regional/global systolic function. Compared with the prior study (images reviewed) of [2117-6-7], the findings are similar. LABS ON DISCHARGE: [2118-7-12] 06:20AM BLOOD WBC-12.1# RBC-3.58 Hgb-12.2 Hct-33.4* MCV-93 MCH-34.0* MCHC-36.5* RDW-14.1 Plt Ct-370 [2118-7-12] 06:20AM BLOOD Glucose-78 UreaN-29* Creat-0.9 Na-132* K-4.0 Cl-94* HCO3-27 AnGap-15 Brief Hospital Course: 1) Shortness of breath - The patient had episodes of tachypnea and wheezing requiring IV solumedrol and BIPAP which she did not tolerate for more than 1/2 hour on night of admission. Given continuous albuterol and ipratropium nebs with good improvement. Had ECHO which yielded nl EF and no evidence of CHF. SOB presumed [2-25] COPD exacerbation. She was continued on IV solumedrol and placed on levaquin for COPD exacerbation. Levaquin was eventually switched to ceftriaxone and azithromycin given a prior history of quinolone allergies. The patient did not require intubation during her MICU course and was called out to the floor on hospital day 4. On the floor, she continued to improve with standing nebs and IV solumedrol was switched to a prednisone taper, which she will complete as an outpatient. The pt will also complete a 10 day course of cefpodoxime and azithromycin and follow up with Dr. [Last Name (STitle) ], her PCP, [Name10 (NameIs) 3] an outpatient. 2) Elevated cardiac enzymes - The pt never complained of chest pain during the hospital coures and did not have ischemic EKG changes. However, due to her SOB, she had enzymes cycled which were positive. CK peaked at 848, CKMB at 108, and troponin at 0.10. Per enzymes, looked like possible NSTEMI vs myocarditis. However, a TTE was WMA and has nl EF making myocarditis more likely, although the pt was without sxs and had no ekg changes. A beta-blocker was not started given active COPD flare. A statin was started in house in addition to aspirin. As the pt remained assymptomatic, a cardiac cath or cardiac MRI was not pursued. She may have further cardiac w/u as an outpatient per her PCP. 3) Hypertension - Continued on verapimil. Benicar and norvasc were restarted prior to discharge. 4) CREST syndrome - Thought to be contributing to pulmonary disease. Is followed by rheumatology at [Hospital1 2177] and not on medications for this at present. She will continue to f/u with her PCP and rheumatologist. 5) Hyponatremia - Has h/o of SIADH with prior baseline Na in 130s; however was noted to have Na down to 120 during hospital course. Renal was consulted and thought that this was most consistent with possible worsening baseline SIADH in the setting of exacerbated pulmonary function. The pt was also noted to be slightly hypervolemic. She was given lasix and fluid restricted to 1L with improvement in her Na back to baseline by the time of discharge. Medications on Admission: Omeprazole 20 mg Norvasc 10 mg Benicar 40 mg Denies ASA 81 mg Albuterol QID Atrovent prn Azithromycin 500 mg x 2 doses Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:0 3. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day for 8 days: [Date range (1) 34558] take 3 pills;[2035-7-15] take 2 pills;[Date range (1) ] take 1 pill. Disp:24 Tablet(s) Refills:0 4. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 6 days: START THIS SCRIPT ON [7-21]!!! [Date range (1) 92874] take 1 pill; [Date range (1) 109368] take half a pill a day. Disp:6 Tablet(s) Refills:0 5. Azithromycin 250 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours) for 4 days. Disp:8 Capsule(s) Refills:0 6. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days. Disp:8 Tablet(s) Refills:0 7. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 9. Benicar 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 10. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Atrovent 0.02 % Solution Sig: Two (2) puffs Inhalation twice a day. Disp:1 inhaler Refills:2 Discharge Disposition: Home Discharge Diagnosis: Pneumonia COPD HTN CAD Scleroderma Discharge Condition: Stable; oxygenating well on RA. Discharge Instructions: You were treated for shortness of breath which was attributed to a combination of COPD and pneumonia. You will need to continue 4 more days of antibitics to fully treat your pneumonia. I have given you prescriptions for cefpodoxime and azithromycin for 4 days. Please take these as instructed. You also need to take prednisone for another 14 days. You will be taking lower doses every 3 days. From [Date range (1) 34558] you will take 60 mg. From [Date range (1) 35547] you will take 40mg. From [Date range (1) ] you will take 20mg. From [Date range (1) 92874] you will take 10mg. From [Date range (1) 109368] you will take 5mg. I have also prescribed you 2 inhaler to take for your lung disease. Please take the albuterol as needed. Please take the atrovent 2 times a day. Please take all medications as prescribed. Please return to the ER for any increasing shortness of breath, chest pain, nausea, vomiting, fevers, or chills. Followup Instructions: Please follow up with Dr [Last Name (STitle) ] in the next 2-3 days. Please call her office for an appointment ([Telephone/Fax (1) 608]). [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(1) 4236] Completed by:[2118-7-14]	[ "710.1", "429.0", "253.6", "443.9", "486", "733.00", "491.21", "401.9", "530.85", "530.81" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	14018, 14024	9902, 12353	318, 325	14103, 14137	6319, 6324	15150, 15420	5435, 5680		12522, 13995		14045, 14082		12379, 12499				14161, 15127											5175, 5191		5695, 6300																										259, 280		9661, 9879					353, 4511									6339, 9642								4533, 5152	5207, 5419
31,442	170,821	30829	Discharge summary	report	Admission Date: [2116-5-14] Discharge Date: [2116-5-19] Date of Birth: [2036-2-26] Sex: M Service: NEUROSURGERY Allergies: Epogen Attending:[First Name3 (LF) 2724] Chief Complaint: Subdural Hematoma and mental status changes. Major Surgical or Invasive Procedure: none History of Present Illness: Pt is an 80 yo male w/ PMHx sig for atrial fibrillation on Coumadin, PM/ICD, HTN, CRI on HD admitted to ED after traumatic fall. Pt apparently had a mechanical fall walking to dialysis this morning. He fell down and hit his head but had no LOC. Upon initial presentation to the ED, the patient was A&O x3 and moving all of his extremities without any asymmetry. CT head showed a small, acute left frontal SAH and a subacute-on-chronic left frontoparietal subdural hematoma. ~ 5 PM the patient was noted to have decompensate, with slurred speech, R facial droop, and decreased movement of R arm. He was intubated for airway protection. Repeat CT scan head performed and showed CT head showed small subdural hematoma, L parietal. Had laceration, occipital. Past Medical History: CABGx5 [2102] pacemaker/icdf implanted '[92] ESRD, on dialysis [Last Name (LF) ], [First Name3 (LF) ], Sat anemia Social History: no ETOH or tobacco, no illicit or IVDU Family History: noncontributory Physical Exam: Vitals: T 97; BP 150/65; P 67; RR 10; O2 sat 100% on vent General: intubated w/ c-collar in place HEENT: posterior laceration Pulmonary: CTA b/l 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: intubated, does not respond to voice Cranial Nerves: PERRL, 4-->2mm with light. + VOR, + corneal reflex, R facial droop. Motor/[Last Name (un) ]: Normal bulk. Normal tone. RLE externally rotated. Minimal withdrawal to pinch L >R. Reflexes: reflexes 3+ on R with upgoing toe, 2+ on L with toe downgoing. Pertinent Results: EEG Study Date of [2116-5-16] IMPRESSION: This is a mildly abnormal portable EEG in the waking and drowsy states due to the bursts of generalized delta frequency slowing. This is a non-specific abnormality suggestive of deep subcortical midline dysfunction. There were no epileptiform discharges noted. Of note, however, there were frequent premature ventricular contractions. L-SPINE (AP & LAT) [2116-5-16] 12:41 PM 1. Degenerative changes of the lumbar spine without acute compression deformities. 2. Dilated loop of featureless bowel within the abdomen, likely colon. This is a nonspecific bowel gas pattern. If there is abdominal pain, dedicated abdominal views could be obtained. CT HEAD W/O CONTRAST [2116-5-15] 5:45 AM NON-CONTRAST CT HEAD: There has been no significant change in acute on chronic subdural hemorrhage along the left cerebral convexity measuring approximately 8 mm in greatest distance off the inner table of the skull with mild associated mass effect. Hyperdense collection of blood within the subarachnoid spaces adjacent to the subdural hemorrhage may be slightly less conspicuous. The approximately 4 mm subfalcial herniation is unchanged. Posterior subgaleal hematoma is again noted with skin staple in place. The and mastoid air cells remain well aerated and an NG tube is partially imaged. IMPRESSION: No significant interval change in the size and appearance of the left subdural hematoma. Unchanged rightward subfalcial herniation. CT HEAD W/O CONTRAST [2116-5-14] 1:30 PM FINDINGS: Along the posterior aspect of the parietal bone, in the superficial tissues, there is an area of soft tissue swelling with hyperdense/hemorrhagic components, several foci of air and two staples consistent with an acute subgaleal hematoma. Along the left parietal convexity, there is a low- attenuation crescentic collection with several hyperdense foci, representing either acute hemorrhage or fibrovascular membranes, consistent with a subdural hematoma. There is a hyperdense fluid- fluid level within the dependent portion of this subdural collection, representing "hematocrit effect." Within the left frontal lobe, just suprajacent to the subdural hematoma, there is a linear hyperdensity within a sulcus, consistent with a small focus of subarachnoid hemorrhage. There is minimal rightward shift of approximately 2 mm. There is no discernable mass effect on the left lateral ventricle. There is no hydrocephalus or major vascular territorial infarction. The density values of the brain parenchyma are maintained. Mild periventricular white matter change is consistent with chronic small vessel disease. Incidental note is made of calcifications of the vertebral arteries, bilaterally. The visualized portion of the paranasal sinuses and mastoid air cells are unremarkable. IMPRESSION: 1. Small, acute left frontal focus of subarachnoid hemorrhage. Likely early subacute-on-chronic left frontoparietal subdural hematoma. Minimal associated mass effect. 2. Posterior parietal subgaleal hematoma, with no skull fracture. CT C-SPINE W/O CONTRAST [2116-5-14] 1:31 PM There is no malalignment or acute fracture of the cervical spine. There is extensive multilevel spondylosis. There is mild neural foraminal narrowing on the left at the C3-4 and C4-5 levels. There is no significant spinal canal stenosis, with CT is unable to provide intrathecal detail comparable to MRI. Incidental note is made of extensive atherosclerotic calcifications of the carotid and vertebral arteries. IMPRESSION: No acute fracture or alignment abnormality. Mild degenerative disease of the cervical spine. Labs: [2116-5-19] 08:00a 134 97 AGap=17 -------------<183 3.4 23 5.5 Mg: 1.9 P: 3.1 MCV 100 WBC 8.3, Hgb 9.2, Hct 26.5, Plates 180 [2116-5-17] Phenytoin: 7.5 [2116-5-16] Digoxin: 2.6 [2116-5-14] 12:20PM PT-17.4* PTT-30.8 INR(PT)-1.6* [2116-5-14] 12:20PM CALCIUM-9.6 PHOSPHATE-4.1 MAGNESIUM-2.1 [2116-5-14] 12:20PM GLUCOSE-136* UREA N-41* CREAT-4.9* SODIUM-141 POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-33* ANION GAP-15 [2116-5-14] 09:54PM PHENYTOIN-14.6 Brief Hospital Course: Mr. [Known lastname 72967] is an 80 yo male w/ PMHx sig for atrial fibrillation, PM/ICDF, ESRD on dialysis who presents after traumatic fall w/small L SAH and SDH subsequently developed R facial weakness, vomiting, and altered MS. The patient was monitored in the ICU setting and subsequently extubated without event. His mental status markedly improved in the early days following admission. At time of discharge he was oriented to place, time, person without significant neurologic deficit. Interval head CT obtained revealed stable subdural hematoma (full results detailed above). He was evaluated by physical therapy who recommended rehab placement given numerous recent falls. Hemodialysis was continued during this admission in addition to Darbepoietin(to which he does not have an allergy) for the pt's chronic anemia. Cardiology consultation was obtained for ? AICD malfunction in the setting of the patient's possible syncopal episode prior to admission. They found the lead placement to be aberrant and suggested further testing for possible lead exchange. This was discussed at length with the patient, his family, and cardiology consultants, and it was decided not to pursue further intervention with regard to his AICD given the associated risks of the procedure. Cardiology further recommended starting metoprolol low dose, stopping digoxin as he is on HD, and starting a statin after checking LFTs and CPK. The patient should follow up with Dr.[Last Name (STitle) 548] in four weeks with an interval CT scan of the head prior to the appointment. The patient will need to schedule a follow up appointment with Dr. [Last Name (STitle) 73] (Cardiology) in [11-19] weeks. Medications on Admission: Coumadin, Nephrocaps, Levothyroxine, Ambien, Niacin, Calcitrol, Lasix, Ferrous Sulfate, Aranesp Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 2 weeks. 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Niacin 500 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO HS (at bedtime). 6. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 10 days. Disp:30 Capsule(s) Refills:0 7. Zolpidem 5 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 8. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO MWF (Monday-Wednesday-Friday). 9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Darbepoetin Alfa In Polysorbat Injection Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: subdural hematoma and subarachnoid hematoma Discharge Condition: neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR HEAD INJURY ??????Take your pain medicine as prescribed ??????Exercise should be limited to walking; no lifting, straining, excessive bending ??????Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ??????Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ??????If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ??????Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ??????New onset of tremors or seizures ??????Any confusion or change in mental status ??????Any numbness, tingling, weakness in your extremities ??????Pain or headache that is continually increasing or not relieved by pain medication ??????Fever greater than or equal to 101?????? F Followup Instructions: PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR.[Last Name (STitle) 548] TO BE SEEN IN 4 WEEKS. YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST PLEASE MAKE A FOLLOW-UP CARDIOLOGY APPOINTMENT WITH DR. [Last Name (STitle) ] IN [11-19] WEEKS. CALL ([Telephone/Fax (1) 12468]. Please let office know that you will need a digoxin level, CPK and liver function tests for this appointment. Your digoxin was discontinued during your hospital stay because your level was 2.6 which is high. Please contact your PCP regarding this.	[ "E888.9", "852.21", "V45.01", "852.01", "427.31", "403.90", "414.00", "585.9", "V45.81" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71", "39.95" ]	icd9pcs	[ [ [] ] ]	8880, 8950	6174, 7876	316, 323	9038, 9062	2016, 2773	10098, 10671	1340, 1357		8023, 8857		8971, 9017		7902, 8000				9086, 10075													1372, 1651																									1670, 1670	232, 278							351, 1114	1739, 1997		2782, 6151								1685, 1723						1136, 1268	1284, 1324
4,611	146,574	6102	Discharge summary	report	Admission Date: [2196-3-6] Discharge Date: [2196-3-9] Date of Birth: [2153-10-14] Sex: F Service: MEDICINE Allergies: Penicillins / Erythromycin Base Attending:[First Name3 (LF) 2181] Chief Complaint: nausea, abdominal pain Major Surgical or Invasive Procedure: left radial arterial line History of Present Illness: Pt is a 42 yo female, h/o DM type I, in USOH until two days ago, friday at 11 pm. She forgot to hook up her insulin pump after a shower. Woke up in the am with vomiting. BS at that time was 500. She reconnected her insulin pump, and still was persistantly vomiting throughout the day, not able to keep down fluids. At 7 or 8 pm, pt pulled out the catheter of the pump and noticed that it was crunched up. In the ED, FS 700, gap 35. Lactate was 4.1, HCO3 was 9. Pt was started on insulin gtt, fluids with bicarb, and gap closed this am. Started on NPH 8 qam, qphs and Humalog sliding scale. * Past 3 weeks with feeling of fatigue and like she was getting sick. No dysuria/vaginal discharge. No abdominal pain. +muscle aches. No cough currently. Decreased appetite x 1 day. Cough many weeks ago but went away since. Past Medical History: 1. DM1 (dxd at age 20; DKA on presentation and one other time) Started on insulin pump in [Month (only) ]. Before that, was on lantus and humalog (NPH and regular before that). Followed by doctor [First Name (Titles) ] [Hospital3 23909]. 2. mitral valve prolapse 3. retinopathy Social History: Pt is a financial analyst. She lives alone. No EtOH. No smoking. Family History: Breast Ca in gma. Physical Exam: T: 99.6 (100.3 m); BP: 120/54 (103-126/45-54); P: 71-76; RR: 20-26 O2: 99 RA I/O [Numeric Identifier 23910]/1790 FS this pm- mid-upper 100s Gen: Young female appears somewhat distressed speaking in full sentences HEENT: OP no exudate. PERRLA. EOMI. Neck: Tenderness to palpation of lymph nodes in submandibular and occipital areas. CV: Tachycardic, S1S2. No M/R/G Lungs: CTA b/l. Good air entry Abd: diffusely mildly tender. +BS. no rebound. no guarding. Ext: Trace edema. DP 2+ Neuro: CN II-XII tested and intact. Pertinent Results: [2196-3-6] 09:38PM GLUCOSE-318* UREA N-20 CREAT-0.9 SODIUM-136 POTASSIUM-3.6 CHLORIDE-110* TOTAL CO2-17* ANION GAP-13 [2196-3-6] 09:38PM CALCIUM-8.4 PHOSPHATE-1.9* MAGNESIUM-1.9 [2196-3-6] 06:27PM GLUCOSE-457* UREA N-20 CREAT-1.0 SODIUM-131* POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-11* ANION GAP-20 [2196-3-6] 06:27PM CALCIUM-7.9* PHOSPHATE-2.6* MAGNESIUM-1.9 [2196-3-6] 11:52AM GLUCOSE-181* UREA N-20 CREAT-0.9 SODIUM-137 POTASSIUM-4.3 CHLORIDE-112* TOTAL CO2-16* ANION GAP-13 [2196-3-6] 11:52AM CALCIUM-8.2* PHOSPHATE-1.8* MAGNESIUM-2.1 [2196-3-6] 09:05AM GLUCOSE-168* UREA N-20 CREAT-0.8 SODIUM-141 POTASSIUM-4.3 CHLORIDE-117* TOTAL CO2-14* ANION GAP-14 [2196-3-6] 09:05AM CALCIUM-7.2* PHOSPHATE-1.2* MAGNESIUM-1.8 [2196-3-6] 09:05AM TSH-0.71 [2196-3-6] 06:00AM GLUCOSE-255* UREA N-22* CREAT-0.9 SODIUM-143 POTASSIUM-4.6 CHLORIDE-117* TOTAL CO2-12* ANION GAP-19 [2196-3-6] 06:00AM CALCIUM-7.0* PHOSPHATE-1.0# MAGNESIUM-1.6 [2196-3-6] 06:00AM WBC-18.3 RBC-3.68* HGB-11.4* HCT-34.6# MCV-94# MCH-31.0 MCHC-33.0 RDW-12.8 [2196-3-6] 06:00AM PLT COUNT-249 [2196-3-6] 03:00AM PO2-123 PCO2-24* PH-7.14* TOTAL CO2-9* BASE XS--19 COMMENTS-NONE SPECI [2196-3-6] 03:00AM GLUCOSE-367* LACTATE-2.3* NA+-142 K+-4.2 CL--115* [2196-3-6] 03:00AM freeCa-1.22 [2196-3-6] 02:48AM GLUCOSE-469* LACTATE-4.1* K+-4.8 [2196-3-6] 02:40AM GLUCOSE-458* UREA N-29* CREAT-1.1 SODIUM-143 POTASSIUM-4.8 CHLORIDE-112* TOTAL CO2-7* ANION GAP-29* [2196-3-6] 01:40AM URINE HOURS-RANDOM [2196-3-6] 01:40AM URINE GR HOLD-HOLD [2196-3-6] 01:40AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.020 [2196-3-6] 01:40AM URINE RBC-0 WBC-1 BACTERIA-RARE YEAST-NONE EPI-1 [2196-3-6] 01:40AM URINE MUCOUS-RARE CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: eval for appendicitis or other source of infxn Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 42 year old woman with DKA, leukocytosis, hypothermic, RLQ abd tenderness. REASON FOR THIS EXAMINATION: eval for appendicitis or other source of infxn CONTRAINDICATIONS for IV CONTRAST: None. CT SCAN OF THE ABDOMEN: CLINICAL INDICATION: Right lower quadrant tenderness. TECHNIQUE: Contiguous axial images are obtained from the lung bases through the symphysis pubis at 5 mm intervals after the administration of oral and IV contrast. The data was then reformatted into the sagittal and coronal planes. There are no prior studies available for comparison. FINDINGS: The lung bases are clear. The liver, spleen, pancreas, and adrenal glands are unremarkable. The gallbladder itself remains unremarkable. There is no intrahepatic or extrahepatic biliary dilatation. The kidneys enhance symmetrically without evidence of hydronephrosis or perinephric stranding. Oral contrast is visualized throughout the distal small bowel and proximal colon. A normal caliber, contrast filled, appendix is identified within the right lower quadrant. No stranding is present in the right lower quadrant. No bowel wall thickening is identified within either the small or large bowel. Evaluation of the pelvic contents demonstrates probable small cysts within each adnexa. A trace amount of fluid in the deep pelvis likely physiologic in nature. No abscess is present. A Foley catheter and punctate area foci of air are noted within the bladder. No lymphadenopathy is detected. Evaluation of the osseous structures demonstrates no evidence of fracture, blastic or lytic lesions. IMPRESSION: No CT evidence of appendicitis. Probable follicular components to the adnexa bilaterally with a trace amount of fluid, which is also likely physiologic. CHEST (PORTABLE AP) [2196-3-6] 10:10 AM CHEST (PORTABLE AP) Reason: eval PNA [Hospital 93] MEDICAL CONDITION: 42 year old woman with hypothermia, unknown source of infection. REASON FOR THIS EXAMINATION: eval PNA HISTORY: A 42-year-old woman with hypothermia, unknown source of infection. Please evaluate for pneumonia. UPRIGHT PORTABLE CHEST ON [2196-3-6] AT 10:00 A.M.: No change from prior study 8 hours earlier. As before, heart is top normal with a left ventricular configuration. No acute infiltrates are seen. UNILAT UP EXT VEINS US LEFT [2196-3-8] 3:54 PM UNILAT UP EXT VEINS US LEFT Reason: LT ARM SWELLING AND PAIN, R/O DVT [Hospital 93] MEDICAL CONDITION: 42 year old woman with DMI admitted with DKA now with LUE swelling and stiffness REASON FOR THIS EXAMINATION: r/o DVT CLINICAL HISTORY: A 42-year-old female with left upper extremity swelling. TECHNIQUE: Upper extremity venous ultrasound with Doppler. FINDINGS: The left internal jugular, axillary, basilic, and brachial veins demonstrate normal compressibility, color flow, and Doppler waveforms. There is lack of compressibility and echogenic clot within the cephalic vein. IMPRESSION: Cephalic venous clot. Brief Hospital Course: # DKA: The patient developed DKA because her insulin pump fell out. When the patient presented to the ED, she was found to have a fingerstick of 700 with an anion gap of 35 and bicarb of 9. She was admitted to the ICU, treated with iv fluids, insulin with improvement of her sxs. Since she had nausea, vomiting, and abdominal pain, an abdominal CT was done looking for appendicitis. Her B were check q hour and she was covered with insulin. Her BS were stable for 24 hours before discharge. # Right basalic vein clot: During her ICU stay, she had an arterial line in her left upper extremity. On transfer to the medicine service, we noted she had swelling of her left upper extremity and US revealed a clot in the cephalic vein. We discussed the potential risks and benefits of a limited course of anticoagulation. We agreed to initiate LMWH and coumadin. Over this night of HD#3, the swelling in her arm is improved. She will follow up with her PCP [Last Name (NamePattern4) ] 3 days. Medications on Admission: Insulin Discharge Medications: 1. Prochlorperazine 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. Disp:30 Tablet(s) Refills:0 2. Enoxaparin Sodium 60 mg/0.6mL Syringe Sig: 0.6 ml Subcutaneous Q12H (every 12 hours) for 4 days. Disp:8 syringe Refills:1 3. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 4. Insulin Regular Human Subcutaneous Discharge Disposition: Home Discharge Diagnosis: DKA superficial venous thrombosis of Left cephalic vein Diabetes Type I Discharge Condition: good Discharge Instructions: Call your PCP if you feel dizzy, are more nauseous, have vomiting, ot if you insulin pump falls out. Use the Lovenox as directed. Your new medicines are Lovenox and coumadin. Apply warm compresses to your left arm as needed with care to place a towel between the heating sourse and your arm. Followup Instructions: You have an appointment with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 16968] on Friday [3-11] at 12:45 PM. You will have your blood drawn then to monitor your coumadin level. You should schedule follow up with your endocrinologist in [2-7] weeks.	[ "V58.61", "250.13", "V58.83", "276.5", "009.1", "424.0", "997.2", "787.01", "453.8", "362.01", "996.57", "250.53", "785.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	8589, 8595	7114, 8106	314, 342	8711, 8717	2171, 4105	9059, 9345	1598, 1617		8164, 8566	6574, 6655	8616, 8690		8132, 8141				8741, 9036													1632, 2152																										252, 276	6684, 7091						370, 1185																	1207, 1499	1515, 1582
3,919	132,512	3631+55491	Discharge summary	report+addendum	Admission Date: [2196-12-10] Discharge Date: [2196-12-28] Service: MICU CHIEF COMPLAINT: Hypoxia, hypotension. HISTORY OF PRESENT ILLNESS: Patient is a [Age over 90 ]-year-old female with recent admission for colonic obstruction, deep venous thrombosis complicated by GI bleed on heparin who developed 80s and increased to 92% on two liters. She was also noted to have a decreased blood pressure to 70/palp which improved with IV fluids. In the emergency room, blood, sputum and urine cultures were sent. The patient was started on Ceftriaxone, Flagyl and Vancomycin for aspiration pneumonia. Chest x-ray demonstrated white out of the right lung with some left lower lobe collapse versus consolidation. ABG on aspiration in the past. PAST MEDICAL HISTORY: 1. Coronary artery disease status post MI times two. 2. PTCA in [2191]. 3. Colonic pseudo-obstruction status post PEG in [2196-11-8]. 4. Guaiac positive stools. 5. Bradycardia status post pacemaker. 6. Anemia. 7. Urinary retention. 8. Increased cholesterol. 9. Hypertension. 10. Dementia. 11. Left lower extremity deep venous thrombosis in [2196-10-9]. 12. Left upper extremity deep venous thrombosis in [2196-11-8]. 13. GI bleed on heparin. 14. Aspiration pneumonia in [2196-11-8]. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Protonix 40 b.i.d. 2. Neutra-Phos. 3. Celexa. 4. Risperdal. 5. Folate. 6. Colace. 7. Epogen. 8. Lopressor. 9. Subcutaneous heparin. SOCIAL HISTORY: Lives in [Hospital ] Rehab. [Name (NI) ] husband is her primary decision maker and her nephew, [Name (NI) ] [Name (NI) 4640] is very involved in her care. PHYSICAL EXAMINATION: Temperature 96.3 F, pulse 63, blood pressure 82/33. Pulse oximetry 99% on nonrebreather. Generally normocephalic, atraumatic in moderate respiratory distress. Head, eyes, ears, nose and throat: Pupils minimally reactive. Neck: Supple, no lymphadenopathy. Heart: Regular, normal S1, S2, no murmurs, rubs, or gallops. Lungs: Coarse rhonchi bilaterally. Abdomen is soft, nontender with mild distention, positive bowel sounds. PEG tube in place. Extremities: No edema. Palpable pulses distally. Neuro: Opens eyes to voice. LABORATORY: White count 18.8, hematocrit 30.4, platelets 221. Sodium 151, potassium 3.8, chloride 118, bicarbonate 28, BUN 50, creatinine 1.2, glucose 87, calcium 8.8, magnesium 1.7, phos 1.5. ALT 13, AST 25, alkaline phosphatase 85, LDH 405, total bilirubin 0.3. Urinalysis with six to 10 RBCs, three to five WBCs, few bacteria, 38 protein, moderate blood, no leukocyte esterase. ABG 7.27, 62, 172 on nonrebreather. Lactate at 1.3. Chest x-ray with persistent right pleural effusion with increase in size, near complete opacification of the right hemithorax. Left lower lobe consolidation versus collapse. EKG per report, normal sinus rhythm with a rate of 63, left bundle branch block and paced. SUMMARY OF HOSPITAL COURSE: 1. CLOSTRIDIUM DIFFICILE COLITIS: Patient was admitted to the Intensive Care Unit and intubated secondary to worsening respiratory status. She had positive Clostridium difficile which was treated with IV and p.o. Flagyl and Vancomycin for one week. She became hypotensive requiring pressors and remained intubated for one week in the Intensive Care Unit. The patient gradually improved. After over 20 liters of IV hydration, she came off pressors. She had no other culture date indicating sepsis. Patient's Clostridium difficile toxin cleared. 2. RESPIRATORY FAILURE: Patient originally required intubation for hypoxia and acidosis. That resolved initially and she was extubated after seven days. The patient went to the floor for three days, developed increasing respiratory and collapse of the right lung secondary to secretions. The patient was brought back to the Intensive Care Unit and intubated on the 15th. She underwent two thoracenteses each withdrawing 1500 cc of fluid. The pleural effusions were exudate. Cytology was negative. Patient was gradually weaned off the ventilator again and extubated. She continued to have persistent respiratory distress requiring frequent suctioning. She was diuresed. The patient had an extremely weak cough and was unable to clear her secretions adequately. She continued to have atelectasis and collapse after her second extubation. 3. CODE STATUS: Multiple family discussions were held with [First Name8 (NamePattern2) ] [Known lastname 4640] and [Last Name (un) 16514] [Last Name (un) 16515], her husband. The family initially wanted everything done in order to prolong her life. She was aggressively treated with intubation and pressors for two weeks. After her second extubation and realization that she is too weak to clear her secretions and continues to having difficulty with plugging and concerns for future aspiration pneumonias, the family discussion with Mr. [Name14 (STitle) 16515] and [First Name8 (NamePattern2) ] [Known lastname 4640], the decision was to make her a DNR, DNR with no further intubations. She was continued on Lasix and given Morphine for comfort. Discharge status will be updated on an addendum. Discharge condition will be updated. DR.[Last Name (STitle) ],[First Name3 (LF) 251] 12-988 Dictated By:[Last Name (NamePattern1) 16516] MEDQUIST36 D: [2196-12-28] 13:15 T: [2196-12-28] 13:13 JOB#: [Job Number 16517] Name: [Known lastname 2583], [Known firstname ] Unit No: [Numeric Identifier 2584] Admission Date: [2196-12-10] Discharge Date: [2196-12-29] Date of Birth: [2106-1-16] Sex: F Service: The patient was transferred to Acove service Intensive Care Unit after being made comfort measures only by family. The patient was initially treated with Morphine intravenous p.r.n. for discomfort but, as her needs increased, she was started on a Morphine drip. The patient expired on [2196-12-29], Immediate cause of death was respiratory arrest, minutes, and congestive heart failure years. Family was notified by Dr. [First Name (STitle) ] [Name (STitle) ] - the husband was spoken to and he requested an autopsy by saying, "Yes, it would be interesting / important to figure out the precise cause of [Name6 (MD) 116] [Name8 (MD) 117], M.D. [MD Number(1) 118] Dictated By:[Last Name (NamePattern1) 1464] MEDQUIST36 D: [2196-12-30] 08:31 T: [2197-1-1] 10:26 JOB#: [Job Number 2585]	[ "V45.82", "511.9", "428.0", "518.0", "294.8", "008.45", "401.9", "518.81", "507.0" ]	icd9cm	[ [ [] ] ]	[ "38.91", "96.72", "96.04", "34.91", "38.93", "33.24" ]	icd9pcs	[ [ [] ] ]																																								2977, 6599				1709, 2949												109, 132							161, 765																	787, 1496	1513, 1686
45,914	165,804	38726	Discharge summary	report	Admission Date: [2143-12-11] Discharge Date: [2143-12-21] Date of Birth: [2059-8-25] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Sulfa (Sulfonamide Antibiotics) / Tetracycline / Novocain / Levaquin / Zoloft / Penicillins Attending:[First Name3 (LF) 922] Chief Complaint: Shortness of breath/Fatigue Major Surgical or Invasive Procedure: 1. Mitral valve replacement with a [Street Address(2) 44058]. [Male First Name (un) 923] Epic aortic valve bioprosthesis reference number [Serial Number 10859], serial number [Serial Number 86046]. 2. Full left-sided Maze procedure with a combination of the AtriCure bipolar Synergy system and a CryoCath with resection of left atrial appendage. 3. Pericardial resection. History of Present Illness: 84 year old female with history of mitral regurgitation and a chronic pericardial effusion who was admitted for shortness of breath this past [Month (only) 359]. She was diuresed with improvement in her symptoms. Her pericardial effusion was again noted however the decision was made not to drain it as the effusion was stable without evidence of tamponade. Her last echocardiogram showed severe mitral regurgitation with mild to moderate tricuspid regurgition. As well she suffers from paroxysmal atrial fibrillation. Given her espisode of heart failure and her severe mitral regurgitation, she has been referred for surgical management. Past Medical History: CARDIAC HISTORY: Diabetes, Hyperlipidemia, Hypertension; history of pericardial effusion (moderate-sized, unclear etiology, identified in [2139] after viral URI symptoms; mild CAD * CABG: None * PERCUTANEOUS CORONARY INTERVENTIONS: None * PACING/ICD: None. PAST MEDICAL & SURGICAL HISTORY: 1. Mild coronary artery disease (no prior cath reports available) 2. Hypertension 3. Hyperlipidemia 4. Non-insulin dependent diabetes mellitus, type 2 5. Obesity 6. Fibromyalgia 7. Osteopenia 8. Irritable bowel syndrome 9. Obstructive sleep apnea 10. h/[Initials (NamePattern4) ] [Last Name (NamePattern4) ]-[Doctor Last Name ] teat ([3-/2142]) 11. Cystic pancreatic mass ([9-/2142]) Social History: Patient lives at home with by herself and is independent in ADLs, IADLs. Denies tobacco use (never smoker) or alcohol use; no recreational substance use. Family History: Denies family history of early MI. Father and sister with arrhythmia, cardiomyopathies, or sudden cardiac death; sister with CAD, colon cancer; father, sister with ovarian and uterine CA - family history of HTN, HLD. Physical Exam: Physical Exam Pulse: 69 Resp: 18 O2 sat: 97% B/P Right: 109/66 Left: 110/60 Height: 60" Weight: 190lbs General: WDWN in NAD Skin: Warm, Dry and intact. No C/C. No lesions or rashes. HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, OP benign, Teeth in fair/poor repair. Neck: Supple [X] Full ROM [X] No JVD Chest: Lungs clear bilaterally [X] Heart: RRR, low pitched II/VI mid-late systolic murmur at LLSB and apex. Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] No Edema Varicosities: Legs obese. There are some superficial varicosities scattered throughout her bilateral lower extremities more noted below the knee bilaterally L>R. Likely not part of GSV tract. Neuro: Grossly intact [X] 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 None appreciated Pertinent Results: [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname 2890] [Hospital1 18] [Numeric Identifier 86047] (Complete) Done [2143-12-13] at 3:58:37 PM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) 177] C. [Hospital Unit Name 927] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2059-8-25] Age (years): 84 F Hgt (in): 60 BP (mm Hg): 134/67 Wgt (lb): 220 HR (bpm): 67 BSA (m2): 1.95 m2 Indication: Intraoperative TEE for mitral valve replacement. Aortic valve disease. Left ventricular function. Mitral valve disease. Pericardial effusion. Preoperative assessment. Prosthetic valve function. Right ventricular function. Shortness of breath. Valvular heart disease. ICD-9 Codes: 786.05, 423.9, 424.1, 424.0, 424.2 Test Information Date/Time: [2143-12-13] at 15:58 Interpret MD: [Name6 (MD) 1509] [Name8 (MD) 1510], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 1510], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2012AW2-: Machine: u/s 2 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Four Chamber Length: 6.0 cm <= 5.2 cm Left Ventricle - Ejection Fraction: 55% >= 55% Findings LEFT ATRIUM: No spontaneous echo contrast in the body of the [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal regional LV systolic function. [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. Severe (4+) MR. TRICUSPID VALVE: Moderate to severe [3+] TR. PERICARDIUM: Moderate pericardial effusion. GENERAL COMMENTS: Written informed consent was obtained from the patient. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions Prebypass No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. [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 descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Severe (4+) mitral regurgitation is seen. Tricuspid regurgitation is [12-27] +. There is a moderate sized pericardial effusion. Dr. [Last Name (STitle) 914] was notified in person of the results on [2143-12-13] at 1500 hours. Post bypass Patient is AV paced and receiving an infusion of phenylephrine and epinephrine. LVEF= 40%. Bioprosthetic valve seen in the mitral position. It appears well seated and the leaflets move well. The tricuspid regurgitation is mild. Aorta is intact post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [Name6 (MD) 1509] [Name8 (MD) 1510], MD, Interpreting physician [Last Name (NamePattern4) ] [2143-12-17] 14:56 [2143-12-19] 04:00AM BLOOD WBC-9.3 RBC-3.23 Hgb-8.9* Hct-26.4* MCV-82 MCH-27.7 MCHC-33.8 RDW-15.3 Plt Ct-160 [2143-12-21] 04:58AM BLOOD PT-22.8* PTT-93.5* INR(PT)-2.2* [2143-12-21] 04:58AM BLOOD UreaN-24* Creat-0.9 Na-134 K-4.2 Cl-92* [Known lastname ],[Known firstname 2890] [Medical Record Number 86048] F 84 [2059-8-25] Radiology Report CHEST (PA & LAT) Study Date of [2143-12-20] 3:30 PM [Hospital 93] MEDICAL CONDITION: 84 year old woman with MAZE/MVR REASON FOR THIS EXAMINATION: interval chnage Final Report PA AND LATERAL VIEWS OF THE CHEST REASON FOR EXAM: Maze. Comparison is made with prior study [12-18]. Right PICC tip is in the upper right atrium. There are persistent low lung volumes. Bilateral atelectasis larger on the left side have improved. Small bilateral pleural effusions are probably unchanged. There is no pneumothorax. Sternal wires are aligned. DR. [First Name (STitle) 3901] [Initials (NamePattern4) ] [Last Name (NamePattern4) 3902] Approved: [First Name9 (NamePattern2) ] [2143-12-20] 10:08 PM Brief Hospital Course: On [2143-12-13] Ms.[Known lastname 75624] was taken to the operating room and underwent Mitral valve replacement with a [Street Address(2) 44058]. [Male First Name (un) 923] Epic aortic valve bioprosthesis, full left-sided Maze procedure with a combination of the AtriCure bipolar Synergy system and a CryoCath with resection of left atrial appendage, Pericardial resection with Dr.[Last Name (STitle) 914]. Cardiopulmonary Bypass Time:120 minutes.Cross-Clamp Time:84 minutes. Please refer to operative report for further details. She tolerated the procedure well and was transferred to the CVICU intubated and sedated. After all sedation discontinued postoperative night she was able to interact by nodding, and would track the nurse in the room. At approximately 1am she was noted to be less responsive, and not to withdraw to pain. The RUE was shaking intermittently. No other signs were noted as facial twitching or foot movements. Vascular Neurology was consulted for evaluation. Head Ct scan was done which showed no acute intracranial pathology, especially no hemorrhage or large mass detected. EEG was consistent with clinical seizure. Phosphenytoin load given and levetiracetam 1g [Hospital1 ]. Etiology of seizures possibly from ischemic stroke. MRI on [12-16] showed:Scattered foci of restricted diffusion identified in both cerebral hemispheres involving the frontal lobes and parietal regions, likely consistent with a thromboembolic ischemic event. Neuro recommended anticoagulation and aspirin. Phosphenytoin was discontinued with initiation of anticoagulation since this can interact with Coumadin. POD#3 she was awake and able to follow verbal commands. She was weaned to extubation. Beta-blocker introduced to rate control her atrial fibrillation. She was bolused with Amiodarone several times and converted to oral dosing. She continued to progress favorably in clinical terms;and currently the only appreciable finding is weakness in the left arm. Speech and swallow evaluation was done and her diet was advanced to full as tolerated. [12-19] she was transferred to the step down unit for further recovery. Physical Therapy was consulted for evaluation of her strength and mobility. She continued to progress and on POD #8 she was cleared for discharge to [Hospital1 ] Rehabilitaion in [Location (un) 86]. All follow up appointments were advised. Medications on Admission: Medications at home: *Coumadin* Metoprolol Tartrate 100 mg Oral Tablet, 1 tablet three times daily Aspirin 81 mg Oral Tablet, 1 po qd Furosemide 40 mg Oral Tablet, Take 1 tablet daily Alprazolam (XANAX) 0.5 mg Oral Tablet, 1 tab tid Albuterol Sulfate (PROAIR HFA) 90 mcg/Actuation Inhalation HFA Aerosol Inhaler, Take 1-2 puffs every 4 to 6 hours as needed Rosuvastatin (CRESTOR) 20 mg Oral Tablet, one daily Pantoprazole (PROTONIX) 40 mg Oral Tablet, Delayed Release (E.C.), 1 tablet daily 30 minutes before first meal. Increase back to twice daily as needed. Diltiazem HCl (CARDIZEM CD) 240 mg Oral Capsule, Ext Release 24 hr, 1 capsule daily Fexofenadine ([Doctor First Name ]) 180 mg Oral Tablet, q tab qd Discharge Medications: 1. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours) for 10 days. 2. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 5 days: After 5 days decrease the dose to 400 mg daily for 1 week, then after 1 week, decrease dose to 200 mg daily. 8. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 9. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 11. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 12. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 14. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 15. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: titrate to an INR of [12-26].5. 16. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for loose stool. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: -Severe mitral regurgitation. -Atrial fibrillation. -Pericardial effusion of unknown etiology which is chronic. -complex partial seizures secondary to ischemic stroke. Past Medical History: 1. Mitral regurgitation 2. Hypertension 3. Hyperlipidemia 4. Non-insulin dependent diabetes mellitus, type 2 5. Obesity 6. Fibromyalgia 7. Osteopenia 8. Irritable bowel syndrome 9. Obstructive sleep apnea 10. h/[Initials (NamePattern4) ] [Last Name (NamePattern4) ]-[Doctor Last Name ] tear ([3-/2142]) - Transfused with 4 Units of RBC 11. Cystic pancreatic mass ([9-/2142]) - Bx negative 12. Mild coronary artery disease (no prior cath reports available) 13. Chronic pericardial effusion 14. Congestive heart failure 15. Atrial fibrillation 16. Esophageal ulcers/GERD 17. Brain Schwannoma's (4 which are stable by MRI) 18. Left metatarsal fracture 19. Type 2 Diabetes 20. Anemia Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: Please call these physicians for an appointment: Surgeon: Dr. [Last Name (STitle) 914] in 4 weeks, [Telephone/Fax (1) ] Cardiologist: Dr. [Last Name (STitle) ] in [1-26] weeks Please call to schedule appointments with your Primary Care: Dr. [Last Name (STitle) ] in [11-25] 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:[2143-12-21]	[ "428.0", "780.39", "428.30", "729.1", "427.31", "401.9", "250.00", "424.0", "997.02", "272.4", "733.90", "423.8", "E878.8", "285.9", "327.23", "434.91" ]	icd9cm	[ [ [] ] ]	[ "96.6", "35.23", "39.61", "37.36", "37.31", "38.93", "88.56" ]	icd9pcs	[ [ [] ] ]	13684, 13754	8801, 11215	398, 804	14690, 14917	3582, 8101	15930, 16430	2386, 2604		11984, 13661	8141, 8173	13775, 13944		11241, 11241				14941, 15907								11262, 11961					2619, 3563																										330, 360	8205, 8778						832, 1476																	13966, 14669	2214, 2370
23,596	163,446	44335	Discharge summary	report	Admission Date: [2159-9-9] Discharge Date: [2159-9-19] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5868] Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: The pt. is an 85 year-old right-handed female who presented on [2159-9-8] after she experienced a syncopal episode. The pt is unclear of the events surrounding her hospitalization, therefore the history is primarily per the pt's daughter. The pt was home alone last night until her daughter returned at approximately midnight. At that time, her daughter found her sitting in a chair, too weak to get up, incontinent of stool. When the daughter attempted to get the pt out of the chair to clean her, she slumped back into the chair, became minimally responsive, and had a "blank stare" for approximately 5 minutes. There was no evidence of abnormal jerking movements. Her daughter noted that her left eye looked "droopy." The pt does not recall the events, but did feel that after she was found by her daughter and before EMS arrived, her speech seemed "slurred." EMS arrived shortly after she was found by her daughter. At that time, she was described as alert, oriented x 3. She was brought to the ED for evaluation. ED notes document "4-/5 strength of upper and lower extremities." She was admitted to the medicine service for work- up of syncope and physical therapy. The primary medicine team noted that the pt had severe bilateral proximal muscle weakness. The pt stated that this had been present since the prior evening. She offered no other complaints at the time of the neurology consult. Specifically, the pt denied headache, loss of vision, blurred vision, diplopia, dysphagia. She denied vertigo. She denied difficulties producing or comprehending speech. She denied focal numbness, parasthesiae. She did admit to progressive difficulty with her gait and multiple falls over the past year. . On review of systems, the pt. denied recent fever or chills. No night sweats or recent weight loss or gain. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: 1. ESRD on HD (M/W/F since [8-16]) 2. h/o AFib with RVR 3. right kidney RAS 4. HTN 5. hypothyroidism 6. dual chamber PPM ([8-16]) for bradycardia with attempts at rate control for AFib 7. ECHO- 1+ MR, LVEF 60% in [7-16] 8. AAA- noted [2150] 9. h/o CHF 10. R IJ dialysis line place [8-16] 11. multiple mechanical falls Social History: Lives with and cares for daughter who is mentally disabled. Strong support system in her other daughter [Name (NI) 2431] who is a hemodialysis nurse. Quit smoking in [8-16]. No EtOH. Family History: Non-contributory Physical Exam: Vitals: T: 96.1 P: 71 R: 16 BP: 117/56 SaO2: 96% 3L General: Awake, alert, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, bilateral carotid bruits appreciated. No nuchal rigidity or cervical spine tenderness Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, paced, nl. S1S2, II/VI HSM at RUSB Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly. Extremities: No C/C/E bilaterally, 1+ radial, DP and PT pulses b/l. Skin: multiple ecchymoses noted over bilateral upper and lower extremities. . Neurologic: -mental status: Alert, oriented x 3. Cannot perform [Doctor Last Name 1841] or DOW backward. Language is fluent with intact repitition and comprehension. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Pt. was able to register 3 objects and recall [1-15] at 5 minutes. There was no apraxia or neglect. . -cranial nerves: Olfaction not tested. PERRL 3 to 2mm and brisk. VFF to confrontation. There is no ptosis bilaterally. Fundoscopic exam limited by corneal clouding. EOMI without nystagmus. Sensation intact to light touch over face. Left nasolabial fold flat. Hearing intact to finger-rub bilaterally. Palate elevates symmetrically in midline. 5/5 strength in trapezii and SCM bilaterally. Tongue protrudes in midline; no fasciculations. . -motor: Normal bulk, tone throughout. No adventitious movements noted. No asterixis noted. No myoclonus noted. . Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [First Name9 (NamePattern2) 2339] [Last Name (un) 938] L 2 4+ 4 5 5 4+ 4+ 3 5 4 4+ 5 4 R 2 4 4 5 5 4+ 4+ 3 5 4 4+ 5 4 . -sensory: No deficits to light touch, pinprick, vibratory sense, throughout. No extinction to DSS. . -coordination: No intention tremor, dysdiadochokinesia noted. FNF could not be accurately performed secondary to proximal muscle weakness. . -DTRs: 2+ biceps, triceps, brachioradialis, 1+ patellar and 0 ankle jerks bilaterally. Plantar response was mute bilaterally. . -gait: deferred. Pertinent Results: Admission Labs: [2159-9-9] 09:10AM CK-MB-NotDone cTropnT-0.19* [2159-9-9] 01:50AM CK(CPK)-85 CK-MB-NotDone cTropnT-0.16* . [2159-9-9] 01:50AM WBC-12.2* RBC-3.65* HGB-11.9* HCT-39.8 MCV-109# MCH-32.5 MCHC-29.8* RDW-17.8* [2159-9-9] 01:50AM NEUTS-91.8* BANDS-0 LYMPHS-5.8* MONOS-2.3 EOS-0.2 BASOS-0 [2159-9-9] 01:50AM PLT COUNT-78# [2159-9-9] 01:50AM PT-13.1 PTT-28.6 INR(PT)-1.1 [2159-9-9] 01:50AM CALCIUM-9.5 PHOSPHATE-2.8 MAGNESIUM-1.5 [2159-9-9] 01:50AM GLUCOSE-108* UREA N-21* CREAT-3.9# SODIUM-141 POTASSIUM-5.7 CHLORIDE-103 TOTAL CO2-27 ANION GAP-17 [2159-9-9] 09:10AM ALT(SGPT)-24 AST(SGOT)-21 LD(LDH)-305* CK(CPK)-41 ALK PHOS-129* TOT BILI-0.4. . CXR ([9-9]): There is again present a dual lead left-sided cardiac [Month/Year (2) 4448] with leads in stable position. A large bore right-sided dialysis catheter is again present with the tip terminating in the right atrium. There has been interval development of bilateral small pleural effusions with associated atelectatic changes. There is mild interstitial prominence without overt edema. Linear atelectatic changes are also noted in the left mid lung zone. The osseous structures are stable. . NCCTH [9-9]: FINDINGS: There is no intraparenchymal or extra-axial hemorrhage. There is no shift of normally midline structures, mass effect or hydrocephalus. Scattered periventricular and subcortical white matter hypodensities are again noted consistent with mild chronic small vessel ischemic change. The visualized paranasal sinuses and osseous structures are within normal limits. IMPRESSION: No intracranial hemorrhage or mass effect. . NCCTH ([9-10]): New small focal hypodensity in left frontal periventricular location, likely a small focus of evolving infarction. No intracranial hemorrhage, midline shift, or change in ventricle size. . NCCTH ([9-11]): No evidence of intracranial hemorrhage or edema. Further evolution of tiny left periventricular white matter area of infarction. . Carotid series: 1. Appearance suggestive of complete occlusion of the left common, internal, and external carotid arteries in the neck. 2. Significant plaque at the origin of the right internal carotid artery, associated with a severe stenosis, estimated between 80 and 99% in diameter reduction. 3. Tardus parvus flow pattern in the left vertebral artery. Antegrade flow in the right vertebral artery. . TEE: Thickened, calcified mitral valve with torn chordae and possible partial flail. At least mild to modertae mitral regurgitation. A valvular vegetation cannot be excluded. If clinically indicated, a TEE may better characterize the basis and severity of mitral valve disease. Compared to the prior study (tape reviewed) dated [2158-8-7], prolapsing, torn mitral chordae are new. The degree of mitral regurgitation appears similar (may be underestimated). . There has been placement of an endotracheal tube, with the tip terminating within 1.5 cm of the carina. The cuff of the tube appears slightly overdistended. A large bore dialysis type catheter, permanent [Month/Day/Year 4448] and feeding tube remain in place, not significantly changed in position. Cardiac and mediastinal contours are stable. There is persistent vascular engorgement and there has been interval worsening of bilateral central alveolar pattern in both lungs. Moderate to large left and moderate right pleural effusions are again demonstrated with interval slight improvement in the left pleural effusion. CXR: [9-18] pulmonary edema. Brief Hospital Course: The patient is a 85 yo woman w/ ESRD on HD, AFib, s/p pacer, who has been having multiple falls and presented again with a fall possibly secondary to syncope. The patient is a 85 yo woman with HTN, Afibb, ESRD, [Month/Day (4) 4448], hypothyroidism, multiple falls who was admitted [9-8] after a syncopal episode, accompanied by slurred speech and a blank stare. She was initially admitted to the medicine for syncopal workup, and noted to have weakness 8/28. She was seen by the stroke team at that point. Then on [9-10] she became almost non-verbal, not following commands, with bloodpressure in the 110's (normally 140's). A repeat CT-head [9-10] showed a L-frontal hypodensity consistent with a small stroke. She was transferred to the ICU for pressure support, to keep her SBP>140. . Neuro: The patient initially responded to the pressors in that she became more alert. She remained unable to follow complicated commands and continued to be encephalopathic. She was able to move both legs, as well as her left arm (limited to movement in her hands), but not her right arm. As these findings could not be explained by her stroke, a CT of the neck was done and cervical spinal stenosis was ruled out. It remained unclear why she was not able to move her arms. Contributing factors might have been her bilateral rotator cuff injury, or the extensive lacerations involving her arms that might have induced pain. US carotids showed: occlusion L-ICA; 80-99% stenosis R-ICA; nl-Rt vert. flow; backfilling in Lt vert. These abnormalities make the patient very vulnarable to decreased blood pressure. Stenting of the R-ICA was recommended in [6-20] wks with angio in 2 months. EEG showed diffuse slowing with in addition focal slowing on L (fronto-central region) with sharp features. This is consistent with encephalopathy. In the course of the hospitalization, due to accompanying medical problems (see below), full pressor support and fluid boluses became insufficient to maintain her blood pressure at a for the patient acceptable level. following these medical problems, the patient's neurological status deteriorated. After discussion with the patient's family, it was decided to make her comfortable, but only after it was tried to reverse her condition with full support, including intubation. . Haematology: Platelets dropped to 17 over the course of the hospital stay. Heparin Abs: negative. ASA was avoided. Hct continued to drop as well. . Cardiovascular: A TTE showed a flailing mitral valve. A TEE to r/o vegetations/embolic source was deferred by the family. Levophed was given to keep BP up and she was started midodrine. Amiodarone was continued for Afibb. . Infectious disease: WBC trended up. As a cellulitis (arm lacerations) was suspected, she was started on vancomycin and gentamycin. Zosyn was added on [9-16] after her bloodcultures were positive. She did not respond to these medications. . Renal: The patient was maintained on HD Sat, Tue, Thurs. This regimen was changed to CVVH after her condition deteriorated. The renal team followed the patient closely. . Endo: She was maintained on an ISS and FSBS. Levothyroxine was continued for hypothyroidism. . Arterial occlusion Upper Extremity: Heparin gtt was started after a cloth was noted in her Right upper extremity. This was stopped after her PLT dropped to 35.000 (heparin abs negative). The family did not want aggressive intervention. . Respiratory: The patient was intubated in AM [9-18] for respiratory failure, likely secondary to sepsis. . FEN: NGT was place and tube feeds were started. . Proph: protonix . Code: made CMO [9-18]. . The patient expired [9-19]. The family was present and did not opt for autopsy. Medications on Admission: CaCO3 500mg qach metop 25mg [Hospital1 ] levoxyl 75mg qday amiodarone 200mg qday nephrocaps calcitriol 0.25mcg qday ECASA 325 mg qday tramadol 25mg po bid Discharge Disposition: Expired Discharge Diagnosis: 1. stroke 2. renal failure 3. atrial fibrillation 4. flailing mitral valve 5. sepsis 6. cellulitis 7. respiratory failure 8. carotid stenosis 9. hypothyriodism 10. hypotension 11. anemia 12. thrombocytopenia Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[2159-9-20]	[ "V45.01", "434.91", "427.31", "785.52", "518.81", "038.10", "682.3", "428.30", "424.0", "995.92", "244.9", "459.89", "403.91", "433.10", "287.5" ]	icd9cm	[ [ [] ] ]	[ "39.95", "96.04", "96.71", "99.04", "00.17", "38.91", "99.05", "96.6", "38.93" ]	icd9pcs	[ [ [] ] ]	12717, 12726	8774, 12507	270, 276	12978, 12987	5190, 5190	13043, 13081	2972, 2990				12747, 12957		12533, 12694				13011, 13020									4020, 5171				3005, 3583																										223, 232							304, 2382						5206, 8751					3598, 4003						2404, 2745	2761, 2956
14,263	168,302	51503	Discharge summary	report	Admission Date: [2177-8-9] Discharge Date: [2177-8-15] Date of Birth: [2135-5-20] Sex: M Service: MICU HISTORY OF PRESENT ILLNESS: The patient is a 42 year African-American male with a history of HIV, hepatitis C cirrhosis, end-stage liver disease, coronary artery disease, status post right coronary artery stent, history of esophageal varices, gastric ulcers, history of chronic ascites, who was admitted on [2177-8-9] after a three day history of fevers, chills, nausea and abdominal pain as well as upper respiratory infection symptoms, including sore throat, rhinorrhea and lightheadedness and headache. The patient has lost 16 pounds in the last three months. HOSPITAL COURSE: The patient went to the Emergency Room with a temperature of 102.3. He also complained of left shoulder and arm pain with movement. The patient was admitted to the hospital and started initially on ampicillin and gentamicin. Briefly, the [Hospital 228] hospital course was complicated by a fever of unknown origin. He was initially empirically treated with a host of antibiotics. It was determined through blood cultures, which grew back positive for [Female First Name (un) 564], that he had candidemia. He was started on AmBisome for treatment. The source of the [Female First Name (un) 564] infection has not yet been found. The patient had a transthoracic echocardiogram performed which revealed no evidence of endocarditis. He also had acute renal failure, with his creatinine climbing from 0.8 at baseline to 7.7. The etiology of his renal failure was thought to be secondary to hepatorenal syndrome as well as prerenal failure, acute tubular necrosis and possibly AIN. The patient did receive dialysis while he was in the Unit (the patient was transferred to the Medical Intensive Care Unit for further treatment on [2177-8-11]). The [Hospital 228] hospital course was also complicated by an anemia. The patient's hematocrit dropped to 26 while he was on the floor and he was transfused accordingly to a hematocrit above 30. Finally, when the patient was initially admitted to the hospital, he had numerous episodes of hypotension, down into the 80s/60s, which initially responded to fluid boluses but, on [2177-8-10], after his hypotension was not responsive to fluid, the Medical Intensive Care Unit team was called to evaluate the patient and it was determined that the patient was to be transferred for further management of his hypotension and his fungemia. Upon transfer to the Medical Intensive Care Unit, the patient's renal failure worsened significantly, to the point where the patient had no urine output, leading to acidemia, hyperkalemia and accumulation of fluid. Dialysis was performed, with little success, on [2177-8-14]. Additionally, the patient's hypotension significantly worsened as well, to the point where the patient needed to be on three pressors, including Vasopressor, Neo-Synephrine and Levophed. His pressure significantly declined to approximately 70s/30s on [2177-8-15]. The patient also had significant coagulopathy present, with an INR that climbed to 5.7 as well as a platelet count in the 40,000s and hematocrit in the mid-20s. He was transfused several units of packed red blood cells, fresh frozen plasma and platelets as needed before procedures were performed. On [2177-8-13], the patient was noted to become increasingly more lethargic and tachypneic, with a declining mental status. Arterial blood gases showed a pH of 7.16, pCO2 36 and pO2 56. It was decided at that time to intubate the patient. Throughout the course of the [Hospital 228] Medical Intensive Care Unit stay, he was ventilated on increasing ventilator support and without much effect. His acidemia progressed as well as his hypoxemia despite maximal ventilation settings. On the morning of [2177-8-14], the patient was found to have pupils which were fixed and dilated, with no corneal reflexes or gag reflex present, and he did not withdraw to pain stimuli in all four extremities. Sedation which had been used for his ventilatory support was shut off. On [2177-8-15], the patient continued to exhibit the same neurological examination as previously, even though his toxicology screen was negative for benzodiazepines and opiates. Throughout the course of the morning of [2177-8-15], the patient's blood pressure trended downward and he had three to five episodes of asystole, which initially were responsive to Atropine and epinephrine. After the fifth episode of asystole, a physician from the Medical Intensive Care Unit team discussed code status with the patient's wife, Mrs. [Known lastname 7262], who agreed to a "Do Not Resuscitate" status. At 9:40 a.m. on [2177-8-15], the patient suffered cardiac arrest and was not resuscitated per "Do Not Resuscitate" status. The patient was pronounced expired at that time. DISCHARGE CONDITION: Expired. DISCHARGE DIAGNOSES: Septic shock. Candidemia. Liver failure. Renal failure. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3851] Dictated By:[Last Name (NamePattern1) 1336] MEDQUIST36 D: [2177-8-15] 16:34 T: [2177-8-18] 11:11 JOB#: [Job Number 25012]	[ "112.5", "042", "584.9", "571.5", "287.5", "285.9", "V45.82", "070.54" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04", "54.91", "39.95", "38.93", "99.15", "38.95" ]	icd9pcs	[ [ [] ] ]				4972, 4982				5003, 5331						720, 4950																																																	161, 702
82,000	144,609	22455	Discharge summary	report	Admission Date: [2131-9-5] Discharge Date: [2131-9-17] Date of Birth: [2075-11-7] Sex: F Service: MEDICINE Allergies: Augmentin / trazodone Attending:[First Name3 (LF) 759] Chief Complaint: hematemesis and melena Major Surgical or Invasive Procedure: Colonoscopy Central line placed Hemodialysis line placed History of Present Illness: 55F w/ DM2, CKD not yet on HD, dCHF, COPD, OSA who presents with hematemesis and bloody stool. Fell down yesterday and hit her abdomen, was initially complaining of abdominal pain in the emergency department. She states she was supposed to start hemodialysis soon. In the ED, initial VS were: 97.4 64 126/46 16 96%. Stool was maroon on guaiac. NG lavage with 500cc no blood, some bile. Receiving FFP 1 unit, vitamin K 10mg, no PRBC given due to delay. PPI drip started. Ocreotide started, but then stopped when history was obtained. CXR shows pulmonary edema questionable consolidation. She received levofloxacin. CT abd/pelvis no acute intraabdominal process or hemorrhage. Transplant surgery evaluated the patient (she recently had a fistula), no surgical intervention needed. GI consulted and suggested likely EGD in AM. Most recent set of vitals 96.7F, 55-65, 128/50, 18, 98% RA. . On arrival to the MICU, she is sleeping and only arousable to vigorous shaking. She opens her eyes and shakes her head no that she does not have pain. Otherwise, she does not answer my questions or interact. Past Medical History: - Diastolic CHF (EF 65% on ECHO in [1-/2131]) - Atrial fibrillation (on coumadin) - Asthma on 2-4L home O2 - Diabetes with retinopathy (legally blind) s/p Pars plana vitrectomy ([2126-8-6]) - Hypertension - Hyperlipidemia - CKD (baseline Cr~4.7-5.4) - Morbid obesity - OSA (not on CPAP) - Depression - S/p foot surgery x 4 (last [9-4], amputation R 5th toe at [Hospital1 112]) Social History: per OMR: History of ETOH abuse, apparently has not consumed ETOH for many years. History of 5 pack years. No other known IVDU. Former nurse. From [University/College ]. 2 sons. Sister participates in her care. She lives alone, has a nurse [First Name (Titles) 1023] [Last Name (Titles) 31486] her medications. Family History: per OMR: Maternal grandmother and two aunts with diabetes. "Strong" history of alcoholism. Physical Exam: ADMISSION EXAM General: Lethargic, snoring, no acute distress, skin cool to the touch, pallor, NG tube with small amounts of maroon material HEENT: Sclera anicteric, MM dry Neck: supple, JVP unable to appreciate CV: RRR, distant heart sounds, no appreciable murmurs Lungs: Decreased breath sounds at bases with crackles Abdomen: soft, obese, grimaces to deep palpation in LUQ and LLQ GU: foley draining some urin Ext: cool, 2+ pulses, fistula on right, no edema Discharge Exam: VS: Afebrile, HR 60s, SBP 130's/70's, 18 94% RA General: no acute distress HEENT: Sclera anicteric, MM dry Neck: supple, JVP unable to appreciate, Left ant. chest tunnelled line w/ minimal amt of incisional erythema. CV: RRR, distant heart sounds, no appreciable murmurs, NL s1 s2 Lungs: reduced breath sounds at bases with crackles Abdomen: soft, obese, denies TTP, no guarding, non-rigid GU: foley in place Ext: cool, 2+ pulses, fistula on right, no edema Pertinent Results: ADMISSION LABS [2131-9-5] 08:30PM BLOOD WBC-7.8 RBC-1.81# Hgb-5.6# Hct-17.4# MCV-96 MCH-31.1 MCHC-32.4 RDW-15.1 Plt Ct-275 [2131-9-5] 08:30PM BLOOD Neuts-78.5 Lymphs-16.1* Monos-4.0 Eos-0.8 Baso-0.6 [2131-9-5] 10:07PM BLOOD PT-55.6* PTT-36.3* INR(PT)-6.0* [2131-9-5] 08:30PM BLOOD Glucose-80 UreaN-111* Creat-5.8# Na-141 K-3.7 Cl-104 HCO3-23 AnGap-18 [2131-9-5] 08:30PM BLOOD ALT-15 AST-19 LD(LDH)-301 CK(CPK)-226* AlkPhos-46 TotBili-0.4 [2131-9-6] 04:41AM BLOOD Albumin-3.8 Calcium-8.1* Phos-6.2* Mg-2.6 [2131-9-5] 08:38PM BLOOD Lactate-1.7 K-3.8 [2131-9-6] 02:56AM BLOOD freeCa-1.05* DISCHARGE LABS: [2131-9-16] 05:34AM BLOOD WBC-6.5 RBC-3.38* Hgb-10.3* Hct-31.2* MCV-92 MCH-30.4 MCHC-33.0 RDW-14.6 Plt Ct-317 [2131-9-6] 04:41AM BLOOD Neuts-91.4* Lymphs-5.2* Monos-2.8 Eos-0.2 Baso-0.3 [2131-9-15] 05:14AM BLOOD PT-14.4* PTT-27.6 INR(PT)-1.2* [2131-9-17] 06:25AM BLOOD Glucose-138* UreaN-59* Creat-4.8* Na-140 K-3.9 Cl-99 HCO3-27 AnGap-18 [2131-9-9] 05:51AM BLOOD ALT-10 AST-15 LD(LDH)-242 AlkPhos-50 TotBili-1.1 [2131-9-6] 04:41AM BLOOD proBNP-8959* [2131-9-5] 08:30PM BLOOD Lipase-55 [2131-9-17] 06:25AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.1 [2131-9-6] 04:41AM BLOOD Hapto-160 [2131-9-12] 10:33AM BLOOD PTH-456* [2131-9-14] 10:16AM BLOOD Vanco-16.6 EGD [2131-9-6] - IMPRESSION Erythema and friability in the stomach body compatible with erosions, possibly from NG suction trauma Erythema and friability in the duodenum compatible with mild duodenitis Polyp in the stomach body Otherwise normal EGD to third part of the duodenum Colonoscopy: [2131-9-7] - IMPRESSION Polyps in the transverse colon Polyp in the descending colon Blood in the whole colon An area of active bleeding with pulsation was located in the cecum. Four clips were applied to this area after which hemostasis was confirmed by visualization. Otherwise normal colonoscopy to cecum Brief Hospital Course: 55 y/o w/ DM2, HTN/HLD, afib on coumadin, end stage renal disease (not yet on HD), presents w/ nausea, vomitting, reported hematemesis and maroon stool, and was found to have a cecum AVM . # GI bleed: Pt presented with HCT of 17.4. She was admitted to MICU. The source of bleeding was initially unclear. Pt was first placed on PPI gtt, intubated for airway protection and underwent EGD. EGD did not review active source of bleed other than possible NGT trauma. Pt underwent colonoscopy on the second day, which reviewed Cecum AVM and was subsequently clipped by GI. She received a total of 8 units of pRBC, and 3 units of frozen plasma for hemodynamic stability. After the procedure, her HCT remained stable. . # Hypoxemia: Pt was intubated initially for airway protection. She continued to require mechanical ventilation for 5 days, most likely secondary to fluid overload from transfusion. Contributing factors leading to her hypoxemia include OSA, reactive airway disease and possible Vent Assoc Pneumonia for which she received Vancomycin for 8 days total. . # Fever: Pt spiked a fever to 101.3 while she was on the ventilator. Sputum culture showed GPC in clusters. She was initially treated with Vancomycin, Tobramycin and Aztreotam. The sputum culture speciated to Staph aureus sensitive to oxicillin. tobramycin and aztreotam were discontinued afterwards. She continued on Vancomycin for total of 8 days. . # ESRD: Pt has ESRD, already considering hemodialysis. We experdiated the placement of HD-tunnel line in the setting of fluid overload. Hemodialysis were performed at bedside for fluid removal. . # HTN: Pt has documented history of hypertension. We held her metoprolol, hydralazine and amlodipine in the setting of GIB. Her blood pressure medication were slowly resumed after achieving hemodynamic stability. Only metoprolol was added back on. # Atrial fibrillation: Pt had documented history of atrial fibrillation, and on coumadin at home. We reserved her INR initially in the setting of GIB. We continued to hold coumadin until readdressing this as an outpatient. When metoprolol 25mg PO BID was restarted, she returned to [Location 213] sinus rhythm. . # DM2: was hypoglycemic at times, and thus initially held her home 75/25 standing insulin but then retarted this of roughly half of her home dose. This can be further titrated once she leaves the hospital if her sugars are elevated. . # Depression: continued paroxetine . Transitions of care: - GI appointment to address polyps and future C-scope as well as to address decision about anticoagualation with pradaxa vs. asa vs. coumadin. - As she was hypoglycemic at times during the admission, we initially held her home 75/25 standing insulin but then retarted this of roughly half of her home dose. This can be further titrated once she leaves the hospital if her sugars are elevated. - Several days before discharge, she had difficulty retaining urine and thus a foley was left in place for a voiding trial to take place once she arrives at rehab. Medications on Admission: warfarin 5 mg daily calcium acetate 667 mg PO TID with meals calcitriol 0.25 mcg daily multivitamin daily docusate sodium 100 mg PO BID paroxetine HCl 60 mg daily ranitidine HCl 150 mg [Hospital1 ] hydralazine 25 mg TID Aranesp (polysorbate) 100 mcg/0.5 mL once monthly simvastatin 80 mg daily furosemide 100 mg daily amlodipine 10 mg daily insulin lispro protam & lispro 100 unit/mL (75-25) 70 units with breakfast, 62units with dinner. ferrous sulfate 325 mg [Hospital1 ] Vitamin D 50,000 unit daily metoprolol tartrate 25 mg [Hospital1 ] Discharge Medications: 1. paroxetine HCl 30 mg Tablet Sig: Two (2) Tablet PO once a day. 2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK ([Doctor First Name ]). 5. multivitamin Tablet Sig: One (1) Tablet PO once a day. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day: hold for diarrhea. 7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. 8. epoetin alfa 10,000 unit/mL Solution Sig: per below Injection 3X/WEEK (MO,WE,FR): 5000 UNIT IV 3X/WEEK (MO,WE,FR) - per [Hospital1 18] renal team . 9. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 10. paricalcitol 5 mcg/mL Solution Sig: per below Intravenous 3X/WEEK (MO,WE,FR): Paricalcitol 2.5 mcg IV 3X/WEEK (MO,WE,FR) . 11. heparin (porcine) 1,000 unit/mL Solution Sig: as directed below Injection PRN (as needed) as needed for line flush: Dialysis Catheter (Temporary 3-Lumen): DIALYSIS Lumens/ DIALYSIS NURSE ONLY: Withdraw 4 mL prior to flushing with 10 mL NS followed by Heparin as above according to volume per lumen. . 12. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 13. insulin lispro protam & lispro 100 unit/mL (75-25) Suspension Sig: 30 units w/ breakfast, 30 units w/ dinner Subcutaneous twice a day. 14. VOIDING TRIAL Patient was discharged with foley catheter because of urinary retention. Please perform voiding trial on [2131-9-19]. Give her 8 hours to void and check bladder scan if hasn't voided at that Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary: Lower GI bleed Pneumonia Secondary: Diabetes End-stage renal disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: It was a pleasure participating in your care at [Hospital1 18]. You were admitted to the hospital for concern of gastrointestinal bleed and that your INR was too high at 6. A bleeding artery was clipped in the colon and you were treated for a pneumonia. You were also started on diaylsis. REGARDING YOUR MEDICATIONS... START: paricalcitol, insulin sliding scale STOP: hydralazine, furosemide, amlodipine, warfarin, ferrous sulfate, CHANGE: insulin lispro 70/30 = DECREASED from 70 units with breakfast, 62 units with dinner. TO 30 w/ breakfast and 30 with dinner and added a sliding scale. Feel free to increase these standing dosages towards her baseline as needed. She was decreased given some hypoglycemia in the peri-MICU period. Otherwise, it is very important that you take all of your usual home medications as directed in your discharge paperwork. Weigh more than 3 lbs. Your anticoagulation will be held unto you see your Gastrointestinal doctor [First Name (Titles) ] [Last Name (Titles) 4939] and a decision will be made with your primary care doctor regarding how to proceed with anticoagulation given your atrial fibrillation. There were also polyps found in your colon that will need to be readdressed with gastroenterology as an outpatient. [Last Name (Titles) ] Instructions: Department: GASTROENTEROLOGY When: FRIDAY [2131-9-21] at 2:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2837], MD [Telephone/Fax (1) 463] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage *Please call the office to reschedule appt if you are unable to make this appt due to dialysis or other reason* Otherwise, please [Hospital Ward Name 4939] with your primary care physician once you leave the rehabilitation facility. Completed by:[2131-9-18]	[ "997.31", "569.85", "535.60", "362.01", "428.32", "278.01", "293.0", "327.23", "276.2", "E934.2", "V11.3", "041.11", "276.0", "V46.2", "369.4", "518.81", "250.41", "V58.61", "V58.67", "585.6", "V15.82", "427.89", "250.51", "211.1", "285.1", "428.0", "276.69", "272.4", "211.3", "311", "403.11", "E879.8", "250.81", "427.31", "275.3", "493.90" ]	icd9cm	[ [ [] ] ]	[ "96.72", "38.91", "96.04", "38.97", "38.95", "39.95", "45.43", "45.13" ]	icd9pcs	[ [ [] ] ]	10652, 10718	5313, 7779	304, 363	10841, 10841	3346, 3971		2279, 2372		8963, 10629		10739, 10820		8384, 8940				11017, 12908					3988, 5290								2387, 2850							2866, 3327																			241, 266							391, 1501											10856, 10993	7800, 8358					1523, 1918	1934, 2263
2,648	106,821	52692	Discharge summary	report	Admission Date: [2110-2-6] Discharge Date: [2110-2-11] Date of Birth: [2033-7-20] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 76-year-old with severe pulmonary hypertension with congestive obstructive pulmonary disease on 4 liters of home oxygen here with altered mental status. Over the last few months she had been doing steadily worse, more dyspneic with exertion, and limited activity. Was seen by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] on [1-24] for worsening and put on seven days of levofloxacin and a steroid taper, as well as having her oxygen increased. She reports feeling better, though not quite back to feeling well. She had never been on oral steroids before. In the past few days, her symptoms have been stable. She was seen by her doctor two days ago and she was brought to Pulmonary Rehabilitation appointment and was okay. On that appointment, her oxygen was increased to 5 liters. The next day she was more sleepy. The doctor did not call her because she was supposed to go out to lunch in the afternoon. When she called in the evening, she was very sleepy. The patient reports feeling confused without remembering much of what was happening in the past few days, unsure if she was taking the right number of pills, and not eating. On baseline, she self disimpacts her rectum and last did this a few days ago noting some fecal incontinence. She also reports worsening shortness of breath. She had a cough that has been dry. Her weight has been fluctuating a great deal from 107 to 117, though on a higher side recently 6 pound weight gain to 124 and worsened lower extremity edema. The left side is greater than the right which always decays when she has more edema. She denies chest pain, sinus symptoms, hemoptysis, no weakness, nausea, vomiting, abdominal pain, although she has been uncomfortable from constipation. In the Emergency Department, she had a respiratory rate of 4 and oxygen saturation of 85% on 5 liters. Narcan 0.3 mg was given with immediate awakening, and then confusion, dry mouth, and dysarthria which resolved. A total of 0.5 mg of Narcan was given, and the initial chest x-ray showed cardiomegaly, bilateral pleural effusions. Blood pressure dropped until 5 pm it was 69 systolic. She was given 500 cc of normal saline and responded to 80-95 systolic. She was started on a stress dose of steroids, right lower lobe pneumonia on chest x-ray. Was treated with Levaquin. PAST MEDICAL HISTORY: 1. Severe pulmonary hypertension by catheterization in [2108]. 2. Systemic hypotension, two vasodilators presumed secondary to congestive obstructive pulmonary disease. 3. Congestive obstructive pulmonary disease with a FVC of 2.2, FEV1 of 0.81, this was 52% of predicted, FEV1/FVC ratio of 55%. 4. Congestive heart failure secondary to diastolic dysfunction in [2106], to have normal coronary arteries on catheterization followed by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. 5. Hypertension. 6. Carcinosarcoma of the uterus status post total abdominal hysterectomy/bilateral salpingo-oophorectomy. 7. Diverticular disease. 8. Anxiety on Valium. 9. Cauda equina syndrome status post laminectomy in [2105] continued. 10. Urinary retention resolved after pessary placement, baseline decrease in lower extremity sensation left greater than right. Perianal sensation, abnormal bowel movements requiring disimpaction. 11. Left cataract. 12. Osteoporosis. ALLERGIES: Penicillin, gives her hives, but she tolerates cephalosporins. Shellfish give her abdominal pain. MEDICATIONS ON ADMISSION: 1. Lasix 60 mg po q day. 2. Flovent 110 two puffs [Hospital1 ]. 3. Combivent two puffs qid. 4. Serevent two puffs [Hospital1 ]. 5. Prednisone taper completed two days ago. 6. Coreg 6.25/3.125. 7. Norvasc 5 mg po q day. 8. Neurontin 900 mg po qid. 9. Colace prn. 10. K-Dur 30 mEq po q day. 11. Valium 2 mg po q am, 1 mg po q hs. 12. Remeron 45 mg po q day. 13. Prilosec 20 mg po q day. 14. Calcium carbonate po tid. 15. Zestril 20 mg po q day. 16. Morphine IR 15 one tablet q6h. 17. MS Contin 30 mg [11-21] [Hospital1 ]. 18. Macrobid 100 mg po q day. 19. Fosamax 70 mg weekly. 20. Temazepam 30 mg po q hs. SOCIAL HISTORY: She lives alone. Daughter and son live nearby. Thirty pack year history, quit 12 years ago. Used to drink a few glasses of alcohol, cut has cut back recently. FAMILY HISTORY: Her mother had a history of lymphoma. Her father with a myocardial infarction at an unknown age. Sister with [Name2 (NI) 499] cancer at age 66. PHYSICAL EXAM ON ADMISSION: Temperature is 96.5, pulse is 75, blood pressure 106/68, respiratory rate of 24, sat 85 which decreased to the 70s and increased to 90's with deep breathes on a Ventimask at 5 liters. In general, she is fatigued appearing, thin-elderly woman in no apparent distress. Her pupils were reactive bilaterally. Irregular and small on the left. Extraocular muscles are intact. The neck was supple. There was jugular venous distention sitting at 60 degrees. Heart: Regular, rate, and rhythm, normal S1, S2 prominent, P2 [12-26] blowing systolic murmur at the left upper sternal border. Decreased breath sounds throughout, no wheezes. Abdomen had positive bowel sounds with diffusely mildly tender and distended. Rectal was guaiac negative in the Emergency Department. Extremity examination showed 3+ left and 3+ right lower extremity pitting edema up to the thighs. Neurologic examination: She was alert and oriented times three. She could give the days of the week forwards and backwards. Cranial nerves II through XII are intact. Reflexes were 2+ and symmetric throughout with downgoing toes. Strength was [3-24] in the upper extremities bilaterally. Some decreased sensation in the left lower extremity to light touch, positive asterixis. LABORATORIES: On admission, white count 9.4, hemoglobin of 12.7, hematocrit of 38.2, platelets of 272. Urinalysis was negative. Glucose 125, BUN 46, creatinine 2.1, which is significantly up from her baseline normal creatinine. Sodium of 126, potassium of 6.5, chloride 88, and bicarbonate of 28. ALT of 84, AST 78, CK of 512, alkaline phosphatase of 251, amylase 38, lipase 4. Troponin 0.3. MB index 4.1. Albumin 3.9, phosphorus 5.6, magnesium 2.4. An arterial blood gas in the Emergency Room showed a pO2 of 76, pCO2 of 71, pH of 7.25, and a total CO2 of 33. She was admitted to the Intensive Care Unit. HOSPITAL COURSE BY SYSTEMS: 1. Pulmonary: Patient's initial hypercarbic respiratory failure was likely due to Narcan overdose of narcotics. There was a question of infiltrate on her initial chest x-ray consistent with pneumonia, and in addition her history of congestive obstructive pulmonary disease along with new abdominal distention and oxygen retention from her increased O2 likely cause of altered mental status and worsened pulmonary status. She was continued on oxygen, given a stress dose of steroids at that time. 2. Cardiology: She was ruled out for myocardial infarction. 3. Renal: Acute renal failure improved rapidly during her stay, etiology unknown. 4. Gastrointestinal: Abdominal CT scan was obtained given the history and increased LFTs. CT scan of the abdomen showed a significant ascites, multiple hepatic lesions consistent with metastatic cancer, a right adrenal mass thought to be an adenoma, retroperitoneal lymphadenopathy, and bilateral pleural effusions. Patient is thought to have metastatic disease from an unknown primary, however, her uterine cancer was the most likely source. She had a paracentesis while in-house, which 1 liter of fluid was removed, however, it was difficult to continue removal of fluid given that it was in multiple pockets in the abdomen. 5. FEN: The patient had hyponatremia likely secondary to ascites and heart failure. She was continued on salt restriction and diuresed. Code status was discussed. The patient is DNR/DNI, wants comfort only. Her pain was controlled with Morphine as needed by a drip and then converted to IV boluses of Morphine and a Duragesic patch. DISCHARGE MEDICATIONS: 1. Lasix 60 mg po q day. 2. Flovent 110 two puffs [Hospital1 ]. 3. Combivent two puffs qid. 4. Serevent two puffs [Hospital1 ]. 5. Prednisone taper completed two days ago. 6. Coreg 6.25/3.125. 7. Norvasc 5 mg po q day. 8. Neurontin 900 mg po qid. 9. Colace prn. 10. K-Dur 30 mEq po q day. 11. Valium 2 mg po q am, 1 mg po q hs. 12. Remeron 45 mg po q day. 13. Prilosec 20 mg po q day. 14. Calcium carbonate po tid. 15. Zestril 20 mg po q day. 16. Morphine IR 15 one tablet q6h. 17. MS Contin 30 mg [11-21] [Hospital1 ]. 18. Macrobid 100 mg po q day. 19. Fosamax 70 mg weekly. 20. Temazepam 30 mg po q hs. 21. Morphine IR sublingual x20 mg po q1h prn. 22. Duragesic 100 mcg patch td q72h. DISCHARGE STATUS: She is being screened for hospice. DISCHARGE CONDITION: Fair. DISCHARGE DIAGNOSIS: Metastatic cancer of unknown primary source. DR.[Last Name (STitle) ],[First Name3 (LF) 251] 12-988 Dictated By:[Last Name (NamePattern1) 9128] MEDQUIST36 D: [2110-2-10] 22:58 T: [2110-2-11] 04:09 JOB#: [Job Number 108710]	[ "428.32", "584.9", "789.5", "518.81", "486", "967.9", "197.7", "496", "428.0" ]	icd9cm	[ [ [] ] ]	[ "54.91" ]	icd9pcs	[ [ [] ] ]				8984, 8991			4480, 4644		8202, 8962		9013, 9289		3661, 4283											6563, 8179																																							159, 2512									4659, 5534					5559, 6535			2534, 3635	4300, 4463
6,145	163,196	17231	Discharge summary	report	Admission Date: [2110-6-10] Discharge Date: [2110-6-13] Date of Birth: [2081-4-17] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 29-year-old woman, with a history of diabetes, hypothyroidism, asthma, schizophrenia, who was living in a long-term care facility. She presented to us as a direct admission for a scheduled bronchoscopy with stent placement scheduled for [6-11]. It was difficult to obtain a history from the patient, but her caregivers from her facility report that she has had about a one year history of airway obstruction, and has had an MR at an outside hospital, and reports are to be faxed to [Hospital1 18]. Caregivers report that the patient has occasional wheezing and difficulty "getting air in." REVIEW OF SYSTEMS: Negative for shortness of breath, wheezing, chest pain, fevers, or chills, and is positive for a loose tooth. PAST MEDICAL HISTORY: 1) Diabetes mellitus, diet controlled, 2) Hypothyroidism, 3) Asthma, 4) Schizophrenia, 5) Bipolar disorder. MEDICATIONS: 1) cogentin 1 mg tid, 2) armour thyroid 60 mg 2 tablets q morning and 1 at night, 3) Vitamin C 3 tablets tid, 4) lithium 300 mg tid, 5) magnesium oxide 400 mg tid, 6) Seroquel 200 mg 2 tablets [Hospital1 ], 7) trazodone 150 mg 1 tablet q hs, 8) depakote 500 mg tid, 9) zinc 50 mg qid, 10) Effexor XR 150 mg qd, 11) Carnitor 330 mg 1 tid, 12) Creon 20 mg 1 tid ac, 13) Klonopin 1 mg [Hospital1 ], 14) fish oil 1 tablet [Hospital1 ], 15) multivitamin 1 tablet [Hospital1 ], 16) Haldol 2 mg [Hospital1 ], 17) colace 100 mg qd. ALLERGIES: 1) penicillin, 2) sulfa. SOCIAL HISTORY: Negative for smoking, alcohol use, or illicit drug use. FAMILY HISTORY: Unknown. PHYSICAL EXAM ON ADMISSION: Temperature 98.5, blood pressure 135/90, heart rate 96, respirations 22, oxygen saturation 98% on room air. Generally, the patient is awake, smiling, verbal but difficult to understand speech. HEENT - oropharynx is clear. Mucosa moist. Sclerae anicteric. Neck exam supple, no lymphadenopathy. Trachea midline. No thyromegaly. Cardiac exam - normal S1, S2, regular rate and rhythm, no murmurs, rubs or gallops. Pulmonary exam - fine inspiratory wheeze in the right upper lobe. Clear to auscultation otherwise, and good aeration throughout. Abdominal exam - obese, soft, nontender, nondistended, normoactive bowel sounds. Extremities - no edema. Vascular exam - 2+ pulses, dorsalis pedis and radial arteries bilaterally. LABS ON ADMISSION: White blood count 7.9, hematocrit 41.0, platelets 151. Sodium 139, potassium 3.9, chloride 97, bicarb 34, BUN 9, creatinine 0.7, glucose 148, calcium 8.9, phosphorus 3.5, magnesium 1.7. SUMMARY OF HOSPITAL COURSE - 1) PULMONARY: A CT airway was done on the day of admission which showed a right-sided aorta with the arch posterior to the airway causing airway compression. A bronchoscopy with stent was performed, and stent was placed at the distal trachea. It was difficult to assess whether there was improvement in patient's symptoms after this procedure. An MRA was done which showed right aortic arch with left-sided descending thoracic aorta. The trachea and esophageal were displaced anteriorly by the aortic arch. The trachea was narrowed by the proximal left common carotid anteriorly and aortic arch posteriorly, and there was a possibility of aortic regurgitation. Overall, the study was considered to be technically suboptimal due to very limited patient cooperation, and it was recommended that further anatomic information be obtained via a contrast enhanced MRI in which the patient is under conscious sedation. Also in terms of the aortic regurgitation, a cardiac echocardiogram was probably necessary to evaluate the situation. Lastly, a barium swallow with small bowel follow through was performed which showed compression of the esophagus by the aortic arch. Throughout her stay, the patient continued to have oxygen desaturation overnight with her oxygen saturation in the mid-80s which was improved when put on 2 liters nasal cannula. Due to the large body habitus of the patient and the desaturations overnight, it was very possible that the patient was experiencing obstructive sleep apnea, and a sleep study was recommended to further evaluate. On the anticipated day of discharge, pt demonstrated increased difficulty breathing with worsening stridor. Plain films and urgent ENT fiberoptic evaluation demonstrated subglottic narrowing. The patient was thus transferred to the ICU for closer monitoring of her respiratory status. The interventional pulmonology team was closely involved in this decision to transfer. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735], M.D. [MD Number(1) 736] Dictated By:[Last Name (NamePattern1) 48294] MEDQUIST36 D: [2110-6-13] 12:55 T: [2110-6-13] 12:03 JOB#: [Job Number 48295] cc:[Last Name (STitle) 48296]	[ "038.11", "295.70", "745.10", "707.0", "518.84", "255.4", "780.39", "482.1", "482.41" ]	icd9cm	[ [ [] ] ]	[ "31.1", "96.6", "96.72", "33.48", "33.21", "39.22", "39.23", "39.57", "43.11", "34.04", "31.79", "38.85", "96.04", "38.93" ]	icd9pcs	[ [ [] ] ]							1728, 1752																																												797, 908												160, 777									2519, 4961								931, 1637	1654, 1711
80,470	161,255	44241	Discharge summary	report	Admission Date: [2105-11-24] Discharge Date: [2105-11-28] Date of Birth: [2035-8-20] Sex: F Service: MEDICINE Allergies: Dextromethorphan Attending:[First Name3 (LF) 134] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Pericardial fluid tap History of Present Illness: 70 yo F w/ HTN, HL presented 3-4 weeks of intermittant chest pain significantly worse over the past 24 hours. She decribes 1 week of fatigue, pre-syncope and swollen arm following a flu shot 4 weeks ago. About 2 weeks ago she presented with sharp, pleuritic, positional CP and was found to be in AF. She was admitted from [11-9] to [11-11]. She was discharged home on beta-blocker but without anticoagulation (pt refused at that time). She was also started on prevacid. About 3-4 days following discharge, she had new chest and throat tightness. She related this to her prevacid, which she stopped. Last night she had sharp stabbing 10/10 chest pain for about six hours that was associatieted with nausea, dyspnea, lightheadedness, and left shoulder pain. She called her doctor who advised her to go to the ED. On review of systems, she notes subjective fevers, chills, and night sweats for the past two weeks, associated with nausea. She had rhinorrhea somewhat increased from baseline. She has also had soft stools and bloating. Other review of systems was 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. In the ED, initial vitals were T 99.6 HR 76 BP 105/77 RR 18 O2 Sat 96/2L. A pulsus was >20. CTA showed large pericardial effusion which was confirmed on an echo RA and RV diastolic collapse, ~2 cm circumferential effusion, and signs of tamponade. She was sent to cath lab for confirmatory catheterization and pericardiocentesis. Taken from admission note Past Medical History: PMH: HTN hyperlipidemia B12 deficiency Anxiety/depression colonic polyps (s/p resection in [2099]), last colonoscopy in [2101] and was clear Basal cell carcinoma (4 lesions removed over 40 years), s/p Mohs surgery obesity. osteopenia s/p L proximal humeral fracture [12-3] after fall, treated nonsurgically. s/p partial thickness rotator cufftear, rx'd with PT. tooth abscess [9-30] TMJ trigeminal neuralgia s/p surgery for Dupuytren's contracture on L. Also has on R, but wants to hold off on surgery s/p tonsillectomy [2059] jaundice age 5 scarlet fever as child Social History: The patient lives with her husband of 53 years in [Location (un) 3146]. She works as an insurance broker. She has four children, 2 daughters (one of whom is a nurse)and two sons. -[Name2 (NI) 1139] history: She smoked for ~ 8 years, 2 packs per day (16 pack years), but quit ~50 yrs ago. -ETOH: She drinks ~ 5 - 6 glasses wine/week. -Illicit drugs: Denies Family History: Family history per OMR: father died @ 72 - [Name2 (NI) 499] CA in 50's, EtOH, hep C, DM, neuropathy, htn, asthma, Prednisone- induced osteoporosis, glaucoma mother died @ 72 - ovarian CA, COPD, lung CA, blood clots, was on Coumadin x 20 yrs, anxiety 2 sisters - 66 - CAD, macular [Last Name (un) ], breast CA [59] - hx bladder CA 1 brother - glaucoma 4 children: oldest son - teacher. youngest daughter - nurse - both a&w 2 middle children in their 40's, not doing well. Daughter has hep C due to IVDA. On SSI. Son EtOH. Physical Exam: VS: T=100.6 BP= 139/71 HR= 84 RR= 17 O2 sat= 97 GENERAL: WDWN female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. CARDIAC: irregularly irregualar, normal S1, S2. No murmurs or rubs. No thrills, lifts. No S3 or S4. CHEST: A pericardial drain is in place with serous to serosanguenous fluid. Resp were unlabored, no accessory muscle use. Anterior breath sounds were clear. ABDOMEN: Soft. Mild hepatic tendernes without HSM. Otherwise non-tender and non-distended. EXTREMITIES: No c/c/e. Cath site was C/D/I without bruit. SKIN: Mutiple small hemangiomas. No petechia. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: [2105-11-26] 05:41AM BLOOD WBC-10.7 RBC-3.64* Hgb-11.4* Hct-33.2* MCV-91 MCH-31.4 MCHC-34.5 RDW-13.3 Plt Ct-436 [2105-11-24] 11:00AM BLOOD Neuts-85* Bands-2 Lymphs-7* Monos-6 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2105-11-24] 11:00AM BLOOD PT-13.4 PTT-24.1 INR(PT)-1.1 [2105-11-24] 11:00AM BLOOD D-Dimer-2399* [2105-11-27] 05:10AM BLOOD Glucose-95 UreaN-11 Creat-0.7 Na-141 K-3.8 Cl-103 HCO3-30 AnGap-12 [2105-11-26] 05:41AM BLOOD ALT-96* AST-66* AlkPhos-198* TotBili-0.4 [2105-11-24] 11:00AM BLOOD Lipase-40 [2105-11-24] 11:00AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2105-11-27] 05:10AM BLOOD Mg-2.4 [2105-11-25] 04:13AM BLOOD TSH-0.85 [2105-11-25] 09:55AM BLOOD [Doctor First Name ]-NEGATIVE [2105-11-26] 05:41AM BLOOD HIV Ab-NEGATIVE [2105-11-24] 01:30PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.011 [2105-11-24] 01:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG [2105-11-24] 06:00PM OTHER BODY FLUID WBC-[Numeric Identifier 961]* Hct,Fl-3.0* Polys-79* Bands-2* Lymphs-10* Monos-5* Macro-4* [2105-11-24] 06:00PM OTHER BODY FLUID TotProt-5.2 Glucose-92 LD(LDH)-559 Amylase-35 Albumin-3.2 [2105-11-24] 6:00 pm FLUID,OTHER PERICARDIAL. GRAM STAIN (Final [2105-11-24]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Final [2105-11-25]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. VIRAL CULTURE (Preliminary): No Virus isolated so far. CT-Angiogram: 1. No evidence for pulmonary embolism. 2. Large simple pericardial effusion with flattening and elongation of the right ventricle suggestive of tamponade. Would recommend evaluation with clinical exam and/or cardiac echocardiogram. 3. Small left simple pleural effusion. Bilateral basilar atelectasis, left greater than right. 4. Mild pulmonary vascular congestion suggestive of mild volume overload. 5. Left thyroid nodule, stable. Can further evaluate with dedicated ultrasound or biochemical markers on a non-emergent basis. . ABDOMINAL ULTRASOUND: 1. No acute intra-abdominal pathology. 2. Hyperechoic focus within the liver likely representing a hemangioma. Can further evaluate with dedicated liver CT on a non-emergent basis. 3. Hyperechoic focus in the left kidney, likely an AML. 4. Small left pleural effusion, better visualized on CT examination from same day. . CHEST XRAY: 1. Interval enlargement of cardiac silhouette, pericardial effusion versus cardiomegaly. 2. Small left pleural effusion with left basilar atelectasis or early pneumonia. . CARDIAC ECHO [11-24]: The interatrial septum is aneurysmal. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. Trivial mitral regurgitation is seen. There is a moderate to large sized pericardial effusion. The effusion appears circumferential. There is right ventricular diastolic collapse/compression, consistent with impaired fillling/tamponade physiology. Compared with the prior study (images reviewed) of [2105-11-11], the pericardial effusion is now much large. POST TAP ECHO [11-24]: There is a very small pericardial effusion. There are no echocardiographic signs of tamponade (RV not well imaged). No right atrial diastolic collapse is seen. Compared with the prior study (images reviewed) of [2105-11-24], the effusion is much smaller. Brief Hospital Course: 70 F with HTN, HL presenting with pleuritic shoulder pain, presyncope, nausea, found to have a pericardial effusion with tamponade. PERICARDIAL EFFUSION: On presenation pt had fluid seen on CTA, found to have an increased pulsus paradoxus, and tamponade confirmed with echo. Pt was taken to cath for tap of pericardial fluid and drain placement. Pt reported immediate eleviation of symptoms with fluid drainage except persistent chest/shoulder pain with deep inspiration. After repeat ECHO showed minimal residual fluid and no sign of recollection or tamponade, and drain produced minimal output, pt's drain was removed. Pt then felt additional relief of pain. Regarding the etiology of the effusion infectious or malignant causes were most likely, as these are the most common sources of pericardial effustion and she has no history of radiation, renal failure or collagen vascular disease. Her family history of breast and ovarian cancer increase the concern for malignant cause, however the acute onset and history of a few weeks of fevers and elevated WBC would favor infectious etiology. Workup included viral, bacterial and fungal cultures, which were all no growth to date at time of discharge. Also checked TSH, [Doctor First Name ], HIV and cytology which were all normal. Pt has unchanged pulmonary nodules regarding which she will follow up with pulmonary, thyroid nodules which will be biopsies on [2105-12-2], and guaiac positive school for which she will schedule outpt followup/workup. ATRIAL FIBRILLATION: Pt presented in atrial fibrillation, not anticoagulated due to pt's wishes. She was continued on Aspirin and was not recommended anticoagulation given the bloody pericardial fluid. Pt was tachycardic early in the admission with an episode of RVR requiring increased dose of beta blockers. Pt was switched from her home atenolol 25mg to Metoprolol 25mg PO BID to have a more consistent rate control. On the day prior to discharge, pt spontaneously reverted to normal sinus rhythm and remained there at a rate of 60s-80s until discharge. Pt is to follow up with Dr [Last Name (STitle) ] regarding anticoagulation in the future after having a repeat echocardiogram to document resolution. It is possible that a slowly growing pericardial effusion or pericardial irritation may have been the cause of the atrial fibrillation. Also possible but much less likely, is that the atrial fibrillation is related to a silent MI, and the pericardial fluid represents a Dressler's syndrome. HYPOXIA: After pt's pericardial fluid was drained she still required significant oxygen supplementation via nasal cannula, especially with movement. A CXR showed a small left-sided pleural effusion, and some atelectasis, consistent with the bronchial sounds heard at the left base on exam. Situation was attributed to atelectasis in the setting of stenting from pleuritic pain. Pt's O2 improved with use of incentive spirometry over time and at discharge she was satting mid to high 90s on room air. ELEVATED LFTS: LFTs on presentation were AST 145, ALT 151, Alk Phos 197 and were attributed to congestion in teh setting of RV failure from tamponade. LFTs trended down throughout the hospital stay. HYPERTENSION: Pt was started on Metoprolol for afib rate control and blood pressures were also well controlled on this regimen thus lisinopril and HCTZ (which were initially held given tamponade physiology) were not restarted. BP was well controlled and at time of discharge pt's SBP was ranging 100s-120s. DEPRESSION: Pt was continued on her outpt regimen of Paxil PROPHYLAXIS: Given the possibility of malignancy causing hypercoagulability and general immobility, pt was on Heparin 5000U TID subcataneously for DVT prophylaxis. Medications on Admission: ATENOLOL - 25 mg Tablet - 2 Tablet(s) by mouth once a day, was only taking 25 mg/day following low blood pressures last week FLONASE - 50MCG Spray, Suspension - ONE SPRAY TWICE A DAY HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth once a day LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day PAROXETINE HCL [PAXIL] - 20 mg Tablet - 1 Tablet(s) by mouth once a day PRAVASTATIN [PRAVACHOL] - 20 mg Tablet - 1 Tablet(s) by mouth 1 po qd ASPIRIN - (OTC) - 325 mg Tablet - 1 Tablet(s) by mouth once a day OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - (OTC) - 20 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [Hospital1 ] (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Pericardial effusion Atrial Fibrillation Discharge Condition: stable Discharge Instructions: You had a pericardial effusion that was tapped to remove the fluid. A repeat cardiac ECHO did not show any reaccumulation of fluid. The fluid showed no signs of cancer or infection. You are also in atrial fibrillation, which converted back to sinus rhythm. If you have any palpitations or symptoms that your atrial fibrillation has returned, please call Dr.[Name (NI) 3588] office. You have an appt with Dr.[Last Name (STitle) ] next month to discuss the atrial fibrillation. You also have multiple follow-up appts to listed below for assessment of your pulmonary and throid nodules. At your follow-up appt with Dr. [Last Name (STitle) 410]. Please stop the following medicines: 1.Lisinopril and HCTZ Please start these new medicines: 1. Metoprolol (this will replace your Lisinopril and HCTZ in lowering your blood pressure and will also control your heart rate in case you revert back to Atrial Fibrillation) Please call your doctor or return to the emergency room if you have any further chest pain, nausea, palpitations, trouble breathing, swelling or any unusual symptoms. Followup Instructions: Pulmonology: Provider: [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. Phone:[Telephone/Fax (1) 612] Date/Time:[2105-12-4] 9:00 Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2105-12-4] 8:40 Provider: [Name10 (NameIs) 1570],INTERPRET W/LAB NO CHECK-IN [Name10 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2105-12-4] 9:00 Cardiology: Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD Phone: [Telephone/Fax (1) 62] Date/Time [2106-1-15] 01:20p ECHO test: 11:00 am on [Hospital Ward Name 23] [Location (un) 436]. Dr. [Last Name (STitle) ] will have the preliminary results of this test for your appt. [Hospital Ward Name ] CLINICAL CTR, [Location (un) ] Primary Care: Provider: [Name Initial (NameIs) ]: Date/Time: [2105-12-7] 02:15p Phone: [Telephone/Fax (1) 1144] [Location (un) ] ([Location (un) 2352], MA), [Location (un) ] Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 410], MD Phone: [Telephone/Fax (1) 1144] DAte/Time: [2105-12-14] 12:30p, [Location (un) ] ([Location (un) 2352], MA), [Location (un) ] [Hospital ] Clinic: Date/Time: [2105-12-10] 09:30a [Hospital Ward Name ] CLINICAL CTR, [Location (un) ] Date/Time: [2105-12-10] 09:30a THYROID NODULE,IMAGING [Hospital Ward Name ] CLINICAL CTR, [Location (un) ] Completed by:[2105-11-28]	[ "241.1", "300.4", "266.2", "578.1", "518.0", "272.4", "518.89", "423.9", "401.9", "427.31" ]	icd9cm	[ [ [] ] ]	[ "88.55", "37.0", "37.21" ]	icd9pcs	[ [ [] ] ]	13047, 13053	8159, 11914	289, 312	13138, 13147	4290, 5736	14288, 15791	2975, 3509		12603, 13024		13074, 13117		11940, 12580				13171, 14265													3524, 4271					5962, 5962			5995, 8136																		239, 251							340, 1968										5818, 5926							1990, 2577	2593, 2959		5768, 5782
76,418	114,836	36147	Discharge summary	report	Admission Date: [2150-1-20] Discharge Date: [2150-2-10] Date of Birth: [2087-9-21] Sex: M Service: SURGERY Allergies: Ampicillin / Piperacillin Sodium/Tazobactam Attending:[First Name3 (LF) 1384] Chief Complaint: Elevated LFTs Major Surgical or Invasive Procedure: [2150-1-22] cholangiogram with liver biopsy [2150-1-29] liver biopsy [2150-2-3] cholangiogram History of Present Illness: 62yM well known to our service who recently underwent a combined liver/kidney transplant. His post-operative course was significant for malnourishment. He required a dobhoff and tube feeds to supplement his nutrition. Once he was medically stable he was transferred to rehab for further rehabilitation. Prior to discharge there was some concern regarding his rising Alk Phos levels, but they trended back down and stabilized so it was decided to send him out with continued follow up. He now returns with findings of eleveated Alk Phos at rehab at 650, AST 30 and ALT 80. He was not having any new symptoms or complaints and states he is doing quite well at rehab. . Past Medical History: Alcoholic Cirrhosis s/p repair of liver laceration Hepatorenal syndrome [2149-12-29] Liver and kidney Transplant Social History: Patient reports heavy alcoholism, but stopped approximately 4 months ago. He reports stopping tobacco use 1 month ago, but prior to that smoked as much as 1.5 ppd. He denies illicit drug use, has no tattoos or piercing and denies a history of blood transfusions. Unmarried, lives in [Hospital1 6687]. Family History: NC Physical Exam: 97.5 80 120/80 18 100 RA PE: Gen- NAD, anicteric, no jaundice, dobhoff in place, still appears malnourished but somewhat improved from prior exams CV-RRR Pulm-unlabored, CTA b/l Abd-soft, NT, ND. Wounds clean/dry/staple lines intact. midline biliary tube in place and capped Ext-1+ edema . LABS: 139 108 27 138 5.5 26 1.0 Ca: 8.5 Mg: 1.3 P: 3.5 ALT: 70 AP: 649 Tbili: 1.0 Alb: 2.8 AST: 31 10 3.0 541 29.8 PT: 13.9 PTT: 31.6 INR: 1.2 Pertinent Results: [2150-2-10] 05:46AM BLOOD WBC-5.3 RBC-2.97* Hgb-9.4* Hct-27.2* MCV-92 MCH-31.6 MCHC-34.5 RDW-17.3* Plt Ct-397# [2150-1-29] 06:01AM BLOOD PT-13.1 PTT-29.0 INR(PT)-1.1 [2150-2-10] 05:46AM BLOOD Glucose-92 UreaN-26* Creat-0.9 Na-137 K-5.1 Cl-104 HCO3-28 AnGap-10 [2150-2-6] 04:13AM BLOOD Glucose-161* UreaN-15 Creat-1.0 Na-136 K-4.5 Cl-101 HCO3-29 AnGap-11 [2150-1-20] 07:10PM BLOOD ALT-70* AST-31 AlkPhos-649* TotBili-1.0 [2150-1-26] 06:05AM BLOOD ALT-90* AST-59* AlkPhos-977* TotBili-0.8 [2150-1-31] 05:47AM BLOOD ALT-54* AST-46* AlkPhos-741* TotBili-0.9 [2150-2-8] 05:48AM BLOOD ALT-45* AST-28 AlkPhos-576* TotBili-0.7 [2150-2-9] 05:40AM BLOOD ALT-38 AST-23 AlkPhos-521* TotBili-0.7 [2150-2-10] 05:46AM BLOOD ALT-33 AST-21 LD(LDH)-202 AlkPhos-446* TotBili-0.6 [2150-2-10] 05:46AM BLOOD Albumin-3.2* Calcium-9.1 Phos-3.8 Mg-1.3* [2150-2-4] 05:14AM BLOOD TSH-3.4 [2150-2-4] 05:14AM BLOOD T4-4.9 T3-60* [2150-2-10] 05:46AM BLOOD tacroFK-10.1 Brief Hospital Course: Admission liver duplex demonstrated no specific son[Name (NI) 493] findings to explain abnormal liver function tests. Hepatic vasculature was patent with normal flow and resistive indices. There was small-volume ascites. On [1-22] a cholangiogram was done to assess for ductal dilatation and assess the vasculature. Post procedure, he spiked a temperature to 104. He was transferred to the SICU for management as he dropped his BP. He was treated with IV fluids and antibiotics were started (meropenum and vanco [1-22]). Blood cultures grew Klebsiella oxytoca and VRE (enterococcus facium). Antibiotics were switched to Dapto and Meropenum after 3 days to Daptomycin and Meropenum. He was treated for a total of 12 days of dapto ([Date range (1) 81979]) and meropenum ([Date range (1) 81980]). Subsequent blood cultures on several days were negative. A right picc line was inserted ([1-27])for IV antibiotics. Biopsy findings demonstrated no intrahepatic duct dilation visualized and no bile leak at the hepaticojejunal anastomosis site. A biopsy was then performed with features representing indeterminate to mild acute cellular rejection. This was treated by increasing his prograf with a target trough level of 15. Prograf levels increased to 15-16 and as high as 18. Dosage was adjusted. LFTs were notable for the alk phos dropping to 612 from 963, but then alk phos continued to rise. On [1-28], an MRCP was performed to assess for biliary obstruction or leak. This demonstrated diffuse mild-to-moderate dilatation of the entire intrahepatic biliary system. There were several foci of intrahepatic biliary stenosis as well as a 2-cm segment of the distal CBD which demonstrated wall thickening and associated luminal stenosis. Distally, the segment abutted the anastomosis of CBD and jejunum. Between the diaphragm and the right lobe of the liver, was a small hematoma. There was a small amount of free fluid around the hepatic and splenic flexure. On [1-29], he was re-biopsied with findings concerning for biliary obstruction or ischemia. Prograf was adjusted. On [2-3], a cholangiogram was done showing no obvious dilation of intrahepatic ducts and possible stricture at lower common bile duct close to the anastomosis site with the contrast flowing freely down to the small bowel. An internal-external biliary draining catheter was placed. After this procedure, LFTs trended down with alk phos decreasing to 446 from 1155 over approximately six days on [2-10]. He developed severe bilateral upper and lower extremity tremors and ataxic gait likely from prograf toxicity causing a significant decline in his ability to ambulate. Neurology was consulted. This was felt to be related to the prograf, but thyroid function studies and a MRI of the head were done to assess his cerebellum. TFTs were significant for a slightly low T3 otherwise TSH and T4 were normal. The MRI was read by neuro and neurosurgery who felt that the MRI was unchanged compared to previous in [2149-11-8], prior to starting on immunosuppression. The two left hemipheric lesions were stable in size, non-enhancing with contrast, and of unclear etiology. His CSF profile [12-8] was normal, with no evidence of inflammation or pleiocytosis. He had CSF PCR negative at that time for HSV/EBV/CMV/[Male First Name (un) 2326]/[Last Name (LF) ], [First Name3 (LF) ] there was no need to repeat a spinal tap. HCV viral load was undetectable. It was not clear what the lesions represented, but given no further growth or lack of enhancement, infection or malignancy were remote possibilities. A repeat MRI brain WITHOUT CONTRAST (as lesions did not enhance and given risk of Nephrogenic Systemic Fibrosis/Nephrogenic Fibrosing Dermopathy)was recommended in 3 months to re-evaluate for evolution of these lesions. With adjustment of prograf, the trough levels decreased to 10 and the tremors diminished. Consequently, his mobility improved. Nutritionally, he required a feeding tube initially, but demonstrated sufficient caloric intake to remove the feeding tube. He was tolerating a regular diet. Vital signs were stable and he remained afebrile. PT worked with daily and recommended [Hospital 41518] rehab. He was accepted at [Hospital1 ]. On the day of discharge, his PTC was removed, but the old insertion site continued to leak some bile. A urostomy pouch was placed over this site to collect and record volume of output. The roux tube that was present since his liver translant surgery was kept capped. Site was without redness or drainage. Twice weekly labs should be drawn for cbc, chem 10, LFTs and trough prograf level with results called to [Hospital1 18] Transplant Office [Telephone/Fax (1) 673]. Medications on Admission: Fluconazole 400', Folic Acid 1',Pred 17.5', Thiamine 100' Bactrim 80-400', MMF [1-8] Pantoprazole 40', Valganciclovir 900', Glargine 12U', Tacrolimus 2.5'' . Discharge Medications: 1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 2. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 10. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Insulin Regular Human 100 unit/mL Solution Sig: follow sliding scale Injection ASDIR (AS DIRECTED). 12. Prednisone 5 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily): follow taper outlined by transplant office. 13. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 14. Prograf 0.5 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: elevated LFTs mild liver transplant rejection biliary stricture tremors secondary to prograf toxicity malnutrition Discharge Condition: stable Discharge Instructions: please call the Transplant Office [Telephone/Fax (1) 673] if fever, chills, nausea, vomiting, inability to take any of your medications, worsening tremors, abdominal pain, diarrhea, redness/bleeding or drainage around capped Roux tube. Labs every Monday and Thursday with results called to the Transplant Office [Telephone/Fax (1) 673] Followup Instructions: Schedule MRI of Head without contrast in 3months {end of [Month (only) 547]) Provider: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2150-2-12] 9:30 Provider: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2150-2-19] 9:00 Provider: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2150-2-26] 9:30 Completed by:[2150-2-10]	[ "V15.82", "E933.1", "038.0", "790.5", "996.82", "E878.0", "998.59", "576.2", "263.9", "E879.8", "781.2", "995.91", "333.1", "789.59", "038.49" ]	icd9cm	[ [ [] ] ]	[ "50.11", "87.51", "51.98", "97.55" ]	icd9pcs	[ [ [] ] ]	9270, 9349	3126, 7900	317, 425	9508, 9517	2107, 3103	9909, 10480	1609, 1613		8113, 9247		9370, 9487		7926, 8090				9541, 9886													1628, 2088																										264, 279							453, 1128																	1150, 1269	1285, 1593
26,889	164,387	21030	Discharge summary	report	Admission Date: [2164-1-4] Discharge Date: [2164-1-8] Date of Birth: [2115-11-4] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2291] Chief Complaint: shortness of breath, cough Major Surgical or Invasive Procedure: None History of Present Illness: 48 y/o Cantonese speaking F with a history of a rt groin synovial sarcoma s/p extensive resection in [2160] presenting with shortness-of-breath, cough and right shoulder pain that started 2 weeks ago. She was in her usual state of health until 2 weeks ago when she developed a persistent cough that continued to progress with subjective low grade fevers and chills at home. She presented to a physician when her cough continued to persist for more than 1 week and she was started a azithromycin approximately 2 days ago. For the past two days she has had increasing difficulty with breathing, particularly when she attempts to lie flat. This morning, she suddenly felt worse with increased work of breathing and presented to the ED at [Hospital1 18]. In the ED inital vitals were T 100.5, HR 100, BP 108/71, RR 20 and 100% on RA. Labs were notable for WBC of 10.6 w/ 0% bands, h/h 9.3/28.3, AST/ALT 67/100, alkphos 275* T.bili, 4.4* Lipase of 93 and lactate of 1.1. CXR showed white out of the RLL (ddx collapse, post obstruction pneumonia vs diaphragmatic collapse) w/ a superimposed right pleural effusion/pleural thickening. Additional findings included a mass in the left mid lung zone and probable lymphadenopathy in a paratracheal distribution all argued in favor of a metastatic process. CT torso demonstrated large low density metastases in the chest on the right w/ a 13cm x 11cm mass collapsing the right lower lobe and compressing the right atrium, shifting the mediastinum to the left. A smaller mass was seen on the left. Findings consistent w/ hepatic and groin mets were also seen. On arrival to the ICU, VS were T 97.8 HR 90 BP 153/90 RR 20 satting 100% on 15L NRB. Review of systems: (+) Per HPI (-) Denies sinus tenderness, rhinorrhea or congestion. Denies nausea, vomiting, diarrhea, constipation or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: [Doctor Last Name 933] dz s/p RAI hypothyroidism HTN Monophasic-type high-grade synovial sarcoma Social History: She does not smoke. She works as at Marshalls in the fitting rooms. Vietnamese speaking female. Family History: Significant for diabetes in her mom Physical Exam: Admission exam: VS: 97.8; 90; 153/90; 23; 100% on NRB GEN: A&O, NAD, accessory muscle usage HEENT: No scleral icterus, mucus membranes dry CV: RRR, No M/G/R PULM: Clear to auscultation left, no breath sounds on the right except in apex. ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses. Left abdominal wall hernia without signs of incarceration. DRE: normal tone, no gross or occult blood Ext: No LE edema, LE warm and well perfused. Well-healed right thigh skin groin Pertinent Results: Admission Labs: [2164-1-4] 03:20PM BLOOD WBC-10.6 RBC-3.65* Hgb-9.3* Hct-28.3* MCV-78* MCH-25.5* MCHC-32.9 RDW-12.7 Plt Ct-340# [2164-1-4] 03:20PM BLOOD Neuts-75.8* Bands-0 Lymphs-17.1* Monos-6.4 Eos-0.5 Baso-0.1 [2164-1-4] 04:24PM BLOOD PT-12.4 PTT-31.5 INR(PT)-1.1 [2164-1-4] 03:20PM BLOOD Glucose-116* UreaN-14 Creat-0.0* Na-132* K-3.8 Cl-96 HCO3-24 AnGap-16 [2164-1-4] 03:20PM BLOOD ALT-67* AST-100* AlkPhos-275* TotBili-4.4* [2164-1-4] 03:20PM BLOOD Calcium-9.3 [2164-1-4] 03:20PM BLOOD TSH-5.0* [2164-1-4] 04:37PM BLOOD Lactate-1.1 CXR [2164-1-4]: There is opacification of the lower right lung zone, with a lucent crescent just superior to the opacified portion. Pleural effusion tracks behind the aerated upper lobe. There is soft tissue thickening along the right main bronchus. An opacity projects over the left mid lung zone. The mediastinal structures are roughly midline, without apparent volume loss. There is no left pleural effusion. Indentations upon the right lateral aspect of the trachea are noted. IMPRESSION: 1. Right lower lung zone white out, which might be the result of airway obstruction with post-obstructive pneumonia, collapse (though lack of volume loss argues against this), or paralysis of the right hemidiaphragm. There is a superimposed right pleural effusion/pleural thickening. Additional findings of a mass in the left mid lung zone and probable lymphadenopathy in a paratracheal distribution all argue in favor of a metastatic process. CT is recommended for further evaluation. 2. The lucent crescent seen adjacent to the lower portion of the aerated left lung is felt unlikely to be free air, though this can be better evaluated with CT. CT Chest/Abdomen [2164-1-4]: IMPRESSION: 1. Pulmonary masses concerning for metastasis, large on the right measuring up to 13cm with significant mass effect causing leftward cardiac and mediastinal shift. 2. Hypodensity within segment III of the liver, new from prior and concerning for focal fatty infiltration versus metastasis. MRI may be performed to further assess. 3. New poorly defined hypodensities in the kidneys, concerning for metastasis vs. infection. 4. Large anterior abdominal wall hernia containing small bowel and colon, uncomplicated. 5. Post surgical changes in the right groin, without definite evidence of local recurrence. Brief Hospital Course: 48F s/p synovial sarcoma resection, now presenting w/ respiratory distress and radiographic evidence of new right lung mass and liver mass and who passed away from hypoxemia from the lung mass. # Respiratory distress/lung metastasis: Patient presented with worsening dyspnea and cough, and was found on CXR and CT scan to have large occlusive mass on the right side, most likely metastatic disease from prior known sarcoma. Thoracic surgery, IP, radiation-oncology and hematology-oncology all consulted and presented various treatment options, with surgery as the most likely definitive care. Extensive goals of care discussions were had involving ICU team, palliative care, social work, and chaplain. Her sister was designated as HCP. Discussion with patient and her sister yielded wish to be [Name (NI) 3225] without further pursue of treatment for metastatic cancer. Morphine drip and ativan prn were started to alleviate respiratory distress. The patient passed away on [2164-1-8] from hypoxemia from the underlying lung mass. Family at bedside. # Hypothyroid: Patient s/p RAI for Grave's. Levothyroxine discontinued once patient [Date Range 3225]. Medications on Admission: Levothyroxine 50mcg daily azithromycin day 3 Discharge Medications: deceased Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased	[ "276.1", "244.9", "197.7", "198.89", "518.0", "486", "293.0", "V49.86", "197.0", "285.9", "244.1", "198.0", "511.9", "V10.89", "518.82", "401.9", "V66.7" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	6870, 6879	5570, 6741	329, 335	6931, 6941	3180, 3180	6998, 7009	2580, 2617		6837, 6847		6900, 6910		6767, 6814				6965, 6975													2632, 3161																					2077, 2323					263, 291							363, 2058						3196, 5547											2345, 2448	2464, 2564
15,311	195,196	48473+59094	Discharge summary	report+addendum	Admission Date: [2148-12-28] Discharge Date: [2149-1-5] Date of Birth: [2067-6-6] Sex: F Service: MEDICINE Allergies: Amoxicillin / Atenolol / Bupropion Hcl Attending:[First Name3 (LF) 4654] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: This is a 81 year old female w/h/o DM2, Alzheimer dementia, and hypothyroidism who was brought in from her NH by EMS w/hypoxia. Per NH report, she had lethargy and decreased po intake last pm; this AM she was found to be hypoxic to 80-82% on RA. Per her daughter, she had been otherwise well. She does note that her mother seemed "fatigued" the last time she saw her. Otherwise, denies that she had complained of F/C, N/V/D/abdominal pain, or chest pain to her knowledge. . In the ED, T 99.2 lowest BP 120s/50s max BP 181/57 HR 80s-90s RR 25 initially O2sat 88% on NRB improved to 99% on NRB w/nebs. ARF to Cr 2.9 from baseline 1.1; cardiac enzymes were elevated w/TNI 0.07. Lactate was 8.0. She received 2L NS as well as IV Vancomycin 1g, IV MetRONIDAZOLE 500mg, and IV Cefepime; she received 10 units of IV insulin and was started on an Insulin gtt. She was noted to be oriented x 3. . Of note, per her last outpt notes, her mental status has been worsening and she spends much of her day in bed. She has been eating less and is completely incontinent and is unable to complete any ADLs by herself. . ROS: The patient is unable to recall why she is in the hospital and currently endorses thirst, otherwise denies any shortness of breath, cough, subjective fevers/chills, weight change, constipation, melena, hematochezia, orthopnea, PND, lower extremity edema- "they are always big", urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: Alzheimers dementia hypertension NIDDM HYPERLIPIDEMIA GOUT ANXIETY ALLERGIC RHINITIS HYPOTHYROIDISM OSTEOARTHRITIS HIATAL HERNIA PAROTID ENLARGEMENT EF >55% on TTE [1-9] s/p bilat cataract [Doctor First Name ]. h/o Acute renal failure [2144] due to sepsis / pneumonia, which resolved. Social History: Lives at [Hospital ] [Hospital ] Nursing Home with her husband. Unable to complete ADLs on her own, daughter involved in her care. No etoh, tobacco, illicits. Family History: Non contributory Physical Exam: Vitals: T: 96.9 BP: 165/49 HR: 80 RR: 26 O2Sat: 98% 15L NRB GEN: alert, conversational, no acute distress HEENT: EOMI, PERRL R>L, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: flat JV, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: soft RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: + LLL consolidation, egophany to mid-lung, otherwise clear on right, no W/R/R ABD: obese, Soft, NT, ND, +BS, no HSM, no masses EXT: 2+ nonpitting edema BL, No C/C, no palpable cords NEURO: alert, oriented to place, for year says "[2075]" for month says "I don't know", has "No idea" why she is here. 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. Pertinent Results: Admission labs: [2148-12-28] 02:30PM BLOOD WBC-26.8# RBC-3.89 Hgb-13.4 Hct-40.1 MCV-103* MCH-34.6* MCHC-33.5 RDW-16.6* Plt Ct-222 [2148-12-28] 02:30PM BLOOD Neuts-59 Bands-20* Lymphs-6* Monos-6 Eos-0 Baso-0 Atyps-0 Metas-7* Myelos-2* [2148-12-28] 02:30PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-1+ Polychr-NORMAL Ovalocy-1+ Acantho-OCCASIONAL [2148-12-28] 02:30PM BLOOD Plt Smr-NORMAL Plt Ct-222 [2148-12-28] 07:54PM BLOOD PT-14.2* PTT-28.3 INR(PT)-1.2* [2148-12-28] 02:30PM BLOOD Glucose-503* UreaN-79* Creat-2.9# Na-132 K-4.4 Cl-87* HCO3-19* AnGap-30* [2148-12-28] 02:30PM BLOOD ALT-26 AST-37 CK(CPK)-213* AlkPhos-127* TotBili-0.7 [2148-12-28] 02:30PM BLOOD CK-MB-11* MB Indx-5.2 proBNP-5025* [2148-12-28] 02:30PM BLOOD cTropnT-0.07* [2148-12-28] 02:30PM BLOOD Albumin-3.8 Calcium-10.4* Phos-5.4# Mg-1.7 [2148-12-28] 02:30PM BLOOD TSH-2.3 [2148-12-28] 02:30PM BLOOD Acetone-NEG Osmolal-328 [2148-12-28] 07:23PM BLOOD Type-ART pO2-64* pCO2-40 pH-7.40 calTCO2-26 Base XS-0 [2148-12-28] 02:34PM BLOOD Glucose-464* Lactate-8.0* [2148-12-28] CXR: IMPRESSION: Suboptimal examination. Large hiatal hernia. New left lower lobe pneumonia. New right middle lobe pneumonia vs. atelectasis. [2148-12-30] TTE: The left atrium and right atrium are normal in cavity size. The left ventricle is not well seen. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are not well seen. No mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: poor technical quality due to patient's body habitus. Left ventricular function is probably normal, a focal wall motion abnormality cannot be fully excluded. The right ventricle is not well seen but is probably dilated with normal function. Probable diastolic dysfunction. No pathologic valvular abnormality seen. Moderate pulmonary artery systolic hypertension. Brief Hospital Course: 81 year old female w/h/o DM2, Alzheimer dementia who was is admitted for HONC and with associated LLL PNA with evident hypoxia. Main items to cont abx below including IV Vanc for 10 days with day 1 [12-31] - check BMP on [1-6] - if Cr 1.0 or less - change levoquin to q24h and vanc to q12 - otherwise continue currently dose. Wean of o2 as tolerated - cont DM mgmt as below. <br> # HONC/diabetes II, uncontrolled, with complications: Calculated osm 320 on admission. Presenting glucose 503. Likely precipitated by PNA. Corrected serum sodium on admission normonatremic at 139, AG was 26. Pt was initially started on an insulin gtt which was switched to insulin SC after AG closed on [12-30]. IVF were started with 1/2 NS which were stopped on [12-30] when pt passed speech and swallow and started to take PO. Electrolytes were checked Q 4hrs which was later spaced out to [Hospital1 ] and repleted PRN. [Last Name (un) ] was consulted on day of admission. -lantus decreased to 30u on [1-1] - BS now controlled (started glyburide on [1-1] as well) - **pm level last pm mod higher (291) - otherwise overall controlled - [Hospital1 1501] to f/u on SSI - adjust SSI vs long-acting insulin as indicated) -re-started glyburide at 5mg [Hospital1 ] [First Name8 (NamePattern2) ] [Last Name (un) 387] on [1-1] -Holding metformin with ARF - pt with likely baseline CRI II if not likely III - may consider d/c long-term - f/u on renal fx and re-start if appropriate -cont appreciate [Last Name (un) 387] recs - please arrange close f/u in next 1-2 weeks with [Last Name (un) 387] <br> # LLL PNA: CXR on admission w/evidence of LLL infiltrate. Pt presented from NH with hypoxia and large A-a gradient. Initially, she was maintained on a non-rebreather then transitioned to NC. On transfer out of the ICU, pt with O2 Sat mid 90's on 4L NC. Pt afebrile since admission, but w/leukocytosis and bandemia resolving at time of transfer. Pt was placed on Vanco/Zosyn/Flagyl initially for coverage of possible aspiration PNA and healthcare associated PND. On [12-31], Flagyl was d/c'd. -tried checking for sputum cx - however pt unable make any sputum also none in unit - given cont to clinically improve - will have to cont vanc given no data to tell otherwise with + improvement -changed vanc to q24h [1-1] with further improving renal fx (still not at baseline, though may now be approaching new baseline) -cont o2 support but with plan to wean as tolerated at [Hospital1 1501] -PT consulted here - did well -****continue levoquin 750mg po qod and vancomycin 1g IV q24h for completion of 10d course (given significant LLL with sig complications in ICU) - Day 1 was [12-31]. -*check BMP on [1-6] - if Cr 1.0 or less - change levoquin to q24h and vanc to q12 -PCP can [Name9 (PRE) 76021] with CXR in 6wks <br> # Leukocytosis/UTI: No h/o diarrhea. Stool was neg for C Diff on [12-29]. Urine culture from [12-28] grew out pan-sensitive klebsiella treated with levofloxacin also used for PNA. WBC now more stable. <br> # abnormal EKG: EKG w/ question of ST depressions in V4-V6 on admission. Pt was briefly put on Heparin gtt for this overnight upon admission but this was d/c'd [12-29] as these changes were not thought to be acute. Also troponins remained flat. She did have a TTE on [12-30] which was of poor quality but showed normal LV and RV function without focal abnormalities. Pt was maintained on BB, ASA, statin. ACE-I was held [3-9] ARF. Changed BB to verapamil on [1-1] as taken prior at home and further monitor. <br> # ARF: Was thought likely pre-renal in etiology. Pt was given IVF as above with Cr trending down to 1.8 from 2.9 at time of transfer (baseline is 1.0 prior) Held nephrotoxic meds and renally dosed meds. Also holding lasix for now, not providing further IVF. Pt remaining overall euvolemic - cr 1.3 at time of transfer to [Hospital1 1501] with further decrease of BUN to 32 (pt did have cr at 1.2 day prior but that was also from further decline from 1.[6-9] now be around new baseline but need to f/u with chem 10 on [1-6]) -*check chem 10 on [1-6] by [Hospital1 1501] -adjust abx as noted above then if indicated -cont to hold lasix - [Hospital1 1501] to re-start if indicated - cont daily wts. <br> # Hypertension: Held antihypertensives initally but then restarted BB on [12-29]. Pt not on one at home - changed back to CaB - verapamil as taken prior. BP overall controlled with this regime. Closely monitor in [Hospital1 1501]. <br> # Alzheimers dementia: Held donepezil and mementine in ICU, re-started on arrival to floor on [12-31]. Geriatrics consulted - will d/c H2 blocker per recs and start ppi. D/C MVI per recs. <br> # Hyperlipidemia: Continued outpt statin. # Hypothyroidism: Continued outpt levothyroxine # Gout: Held allopurinol in the setting of ARF . # FEN: regular, diabetic at time of transfer . # Access: PIVs . # PPx: ppi, heparin SC . # Code: DNR, intubation ok . # Dispo: transfer back to [Name (NI) 1501] (husband noted also there) . # Comm: [Name (NI) 3692] [Name (NI) ] daughter/HCP Phone: [Telephone/Fax (1) 102055] Medications on Admission: ALLOPURINOL 300 mg once a day ATORVASTATIN 80 mg once a day DONEPEZIL 10 mg at bedtime FEXOFENADINE 180 mg every morning FUROSEMIDE 40 mg once a day GLIPIZIDE 5 mg Tab,Sust Rel once a day LEVOTHYROXINE 50 mcg once a day LISINOPRIL 40 mg once a day MEMANTINE 5 mg Tablet twice a day METFORMIN - 1000 mg once a day VERAPAMIL - 240 mg Tablet Sustained Release twice a day ASPIRIN 81 mg once a day with food multivitamin Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 9. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 6 days. 10. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 11. Memantine 5 mg Tablet Sig: One (1) Tablet PO qdaily (). 12. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q 12H (Every 12 Hours). 13. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 15. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours) for 6 days. 16. Insulin Glargine 100 unit/mL Cartridge Sig: One (1) 28 Subcutaneous at bedtime: include routine regular insulin sliding scale qac, qhs. Discharge Disposition: Extended Care Facility: [Hospital ] [Hospital ] Nursing Home - [Location (un) ] Discharge Diagnosis: Primary Diagnosis: HONC/uncontrolled diabetes Hospital aquired pneumonia Urinary tract infection Acute Renal Failure Secondary Diagnosis: Hypertension Alzheimer's Dementia Hyperlipidema Hypothyroidism Gout Discharge Condition: stable for transfer to [Hospital1 1501] Discharge Instructions: Please take medications as prescribed. Use oxygen as needed but your [Hospital1 1501] will try to reduce your requirements as tolerated till you don't need any more. We also also recommended to hold your lasix till further evaluated next week by your doctors at your [Name5 (PTitle) 1501]. Followup Instructions: 1. Please arrange f/u with PCP [Last Name (NamePattern4) ] 2 weeks [Last Name (LF) ],[First Name3 (LF) ] S. [Telephone/Fax (1) 1144] <br> 2. Please arrange [Hospital ] clinic f/u in [2-7] weeks for Diabetes mgmt. <br> 3. PCP to arrange [Name Initial (PRE) ]/u CXR in 6 wks. [First Name8 (NamePattern2) ] [Name8 (MD) 474] MD [MD Number(2) 4658] Completed by:[2149-1-3] Name: [Known lastname 16464],[Known firstname 3192] Unit No: [Numeric Identifier 16465] Admission Date: [2148-12-28] Discharge Date: [2149-1-5] Date of Birth: [2067-6-6] Sex: F Service: MEDICINE Allergies: Amoxicillin / Atenolol / Bupropion Hcl Attending:[First Name3 (LF) 1152] Addendum: Pt's d/c held on [1-3] [3-9] to lack of access for [Hospital1 1354] - wanted PICC and we weren't able to get one at bedside [1-3]. With difficulty IV nurse able to get midline late [1-3] - d/c held given deemed unsafe for transfer later in evening on [1-3] by [Hospital1 1354]. On [1-4] - pt with new complaint of feeling weak - given lack of usual complaints - noted intact neuro exam, CXR with noted more new atelectasis on R base - pt given incentive spirometer. Also pt's renal fx further improved to Cr. 1.0 - abx were subsequently changed to vanc q12h and levoquin q24h - will need to cont this regime now and f/u on Chem 10 on [1-6] at [Hospital1 1354] and adjust abx dosing as appropriate. Given sx pt still observed overnight - on [1-5] pt felt better - d/w [Hospital1 1354] ok with accepting pt with midline and will address further if clinically indicated at [Hospital1 1354]. Stable for transfer - will need to cont aggressive pulm rehab - more insentive spirometer use and general PT as pt has not been moving much while in-house and directly related to more rapid recovery. No change in DM regime as in initial summary except Lantus dose at end was 28units - to cont po hypoglycemic medications. <br> Also with x-ray findings - cont to monitor daily wts and resp exam - once renal fx established as more stable can slowly re-introduce lasix as taking 40mg qdaily prior and held at time of d/c with recovering renal fx. Pertinent Results: [1-4] CXR: IMPRESSION: Patchy opacity left lung base with small left pleural effusion. Small right pleural effusion, patchy atelectasis right lung base. Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 9. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 4 days: final day of treatment is [2149-1-9]. 10. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 11. Memantine 5 mg Tablet Sig: One (1) Tablet PO qdaily (). 12. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q 12H (Every 12 Hours). 13. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 15. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous every twelve (12) hours for 4 days: final day of treatment is [2149-1-9], will need pm dose as well on [1-5]. 16. Insulin Glargine 100 unit/mL Cartridge Sig: One (1) 28 Subcutaneous at bedtime: include routine regular insulin sliding scale qac, qhs. Discharge Disposition: Extended Care Facility: [Hospital ] [Hospital 345] Nursing Home - [Location (un) ] Discharge Diagnosis: Primary Diagnosis: HONC/uncontrolled diabetes Hospital aquired pneumonia Urinary tract infection Acute Renal Failure Secondary Diagnosis: Hypertension Alzheimer's Dementia Hyperlipidema Hypothyroidism Gout Discharge Condition: stable for transfer to [Hospital1 1354] with midline IV access as d/w [Hospital1 1354] prior to d/c Discharge Instructions: Please take medications as prescribed. Use oxygen as needed but your [Hospital1 1354] will try to reduce your requirements as tolerated till you don't need any more. We also also recommended to hold your lasix till further evaluated next week by your doctors at your [Name5 (PTitle) 1354]. <br> Most importantly, please use the incentive spirometer q2 hours and very importantly try to participate with physical therapy as much as possilble as your safe recovery (along with mild swellings in your legs/arms) will be related to that participation. Followup Instructions: 1. Please arrange f/u with PCP [Last Name (NamePattern4) ] 2 weeks [Last Name (LF) ],[First Name3 (LF) ] S. [Telephone/Fax (1) 227] <br> 2. Please arrange [Hospital 616] clinic f/u in [2-7] weeks for Diabetes mgmt. <br> 3. PCP to arrange [Name Initial (PRE) ]/u CXR in 6 wks. [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 1155] Completed by:[2149-1-5**]	[ "272.4", "585.9", "799.02", "486", "276.51", "584.9", "410.71", "599.0", "294.11", "041.3", "250.22", "244.9", "V58.67", "403.90", "274.9", "331.0", "715.90" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	18168, 18265	5898, 11158	306, 312	18518, 18628	16286, 16447	19235, 19682	2391, 2409		16470, 18145		18286, 18286		11184, 11603				18652, 19212													2424, 3286																										259, 268							340, 1869				18427, 18497		3321, 5875	18305, 18406										1891, 2191	2207, 2375
29,378	199,531	48994	Discharge summary	report	Admission Date: [2165-9-10] Discharge Date: [2165-9-17] Date of Birth: [2095-10-11] Sex: F Service: MEDICINE Allergies: Penicillins / Cipro Cystitis / Aspirin / Nsaids / Dicloxacillin / Aldomet / Motrin / Lisinopril / Vioxx Attending:[First Name3 (LF) 602] Chief Complaint: AMS Major Surgical or Invasive Procedure: None History of Present Illness: 69F with hx of CAD, dCHF, dementia/psychosis baseline oriented X 2, presents with AMS from nursing home today. Reportedly was unresponsive for unclear period of time at [Name (NI) ]. In ambulance with a "mild" shaking of the bilateral arms, not the legs, eyes rolled back, reportedly improved after 1 mg of Ativan given by EMS. She has had multiple recent admissions for psychosis/halllucinations, with mental status changes thought secondary to her antipsychotics. . In ED, patient oriented x1. Initial VS not recorded. She spiked to 100.5. Has mid line in place for IV Zosyn and Flagyl for treatment of pneumonia. Recently dc'd from [Hospital1 18] to [Hospital 671] [Hospital ] Rehab. Started on seroquel just prior to dc to rehab. Recently discharged after lengthy hospitalization for UTI, mental status changes, thought due to atypical NMS, during which time her Seroquel was stopped and then restarted. She had been evaluated by psychiatry during that admission as well. At time fo this current admission, electrolytes with creatinine 1.0. CBC with WBC 10.8, NL diff, Hct and platelets. Lactate 1.2. CXR showed no acute infectious process. UA showed >182 WBC, mod bacteria, mod leuk, neg nitrite. Coags were negative. CT head showed no acute intracranial process without change from [9-4]. She was given Blood and urine cultures were sent. Ceftriaxone in ED at 20:00. She was also given Tylenol. Repeat exam at 2300 showed her to be awake, however more lethargic, is not answering questions or following commands. . LP attempted and unsuccessful. Found to be difficult [1-30] body habitus and not able to cooperate w/ positioning. . VS on transfer were 120, 166/63, 34, 97/2L. 3rd liter of IVF hanging. . On the floor, she is not cooperative. Follows some commands. . Labs from rehab from [9-8] show NL CBC, positive UA. . Review of systems: Unable to obtain. Past Medical History: #. DM2 - oral meds. #. CAD s/p MI '[46] - does not tolerate aspirin or ACE -> on Plavix #. diastolic CHF, EF > 55% 7/08 #. HTN #. Restrictive lung disease - not on home O2. FEV/FVC 108%, FVC 45%, FEV1 48% 6/07. #. h/o R LE DVT, many years ago per pt #. discoid lupus erythematosus #. h/o CVA - MRI in [2156] w/ moderate microvascular changes in the cerebral white matter #. h/o of SVT #. schizo-affective disorder #. dementia #. GERD c/b short segment [Last Name (un) 865] and hiatal hernia #. h/o cellulitis #. h/o seizures, per pt many years ago, not on medications #. s/p total abdominal hysterectomy #. small bowel obstruction s/p ex lap w/ lysis of adhesions and partial small bowel resection ([2162-7-30]) #. OSA, does not use CPAP #. OA #. osteopenia Social History: Resides in [Last Name (un) 4367] [Hospital3 400] Facility where she has meals prepared. She dresses and bathes herself at baseline per recent d/c summary. She is able to see her family members frequently. She smoked 2ppd for 20 yrs, but quit in [2162-6-29]. She uses a walker for ambulation. Family History: Father: Died of MI at less than 50 years of age. Mother: History of breast CA. Physical Exam: Admission physical exam Vitals: 98.9, 122, 166/89, 93/2l General: not responsive, withdrawas to pain and keeps limbs up against gravity with + hypertonia/myoclonus HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley, placed in our ED Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge PE: VS: T97 98 16 137/79 98 on RA General: NAD, sitting up in chair, breathing comfortably, interactive, talkative, responding to questions, conversational Neck: supple Lungs: CTA b/l CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: [5-2] LE/UE strength, normal sensation Pertinent Results: Admission labs: [2165-9-9] 07:48PM BLOOD WBC-10.8 RBC-4.77 Hgb-12.9 Hct-39.8 MCV-83 MCH-27.1 MCHC-32.5 RDW-16.2* Plt Ct-292 [2165-9-9] 07:48PM BLOOD Neuts-76.6* Lymphs-17.8* Monos-3.3 Eos-2.0 Baso-0.3 [2165-9-9] 10:18PM BLOOD PT-14.3* PTT-23.6 INR(PT)-1.2* [2165-9-9] 07:48PM BLOOD Glucose-175* UreaN-21* Creat-1.0 Na-145 K-4.2 Cl-110* HCO3-20* AnGap-19 [2165-9-10] 10:00PM BLOOD Type-ART Temp-38.1 pO2-114* pCO2-45 pH-7.37 calTCO2-27 Base XS-0 Intubat-NOT INTUBA [2165-9-9] 08:10PM URINE Color-Yellow Appear-Cloudy Sp [Last Name (un) ]->1.030 [2165-9-9] 08:10PM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-40 Bilirub-LG Urobiln-1 pH-5.0 Leuks-MOD [2165-9-9] 08:10PM URINE RBC-47* WBC->182* Bacteri-MOD Yeast-MANY Epi-0 [2165-9-9] 08:10PM URINE CastGr-6* [2165-9-10] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT [2165-9-9] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [Hospital1 ] [2165-9-9] URINE URINE CULTURE-FINAL {YEAST} EMERGENCY [Hospital1 ] [2165-9-9] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [Hospital1 ] Discharge Labs: [2165-9-15] 10:45AM BLOOD WBC-7.1 RBC-4.54 Hgb-12.3 Hct-37.9 MCV-84 MCH-27.1 MCHC-32.5 RDW-15.9* Plt Ct-324 [2165-9-16] 01:05PM BLOOD WBC-9.2 RBC-4.90 Hgb-13.3 Hct-40.5 MCV-83 MCH-27.1 MCHC-32.7 RDW-16.0* Plt Ct-362 [2165-9-15] 10:45AM BLOOD Glucose-177* UreaN-19 Creat-0.9 Na-138 K-4.0 Cl-102 HCO3-29 AnGap-11 [2165-9-16] 01:05PM BLOOD Glucose-243* UreaN-23* Creat-1.1 Na-139 K-4.0 Cl-102 HCO3-26 AnGap-15 [2165-9-15] 10:45AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.3 [2165-9-16] 01:05PM BLOOD Calcium-9.2 Phos-2.2* Mg-2.3 Imaging: CT head FINDINGS: There is no acute intracranial hemorrhage. The [Doctor Last Name 352]-white matter differentiation appears preserved. There is no edema or mass effect. There is a similar appearance to the right frontal encephalomalacia. Additional hypodensity in the periventricular region is compatible with small vessel ischemic change. The ventricles and sulci are unremarkable given the patient's age. The visualized portion of the mastoid air cells and paranasal sinuses are clear. IMPRESSION: No acute intracranial process. CXR: FINDINGS: There has been interval removal of the right central line and endogastric tube. The heart size is enlarged, similar to slightly improved compared to prior study. The mediastinal contours are within normal limits. The lungs show no lobar consolidation, although the pulmonary vasculature does appear mildly engorged. There is no large pleural effusion or pneumothorax. IMPRESSION: Mild pulmonary vascular congestion, but no heart failure or pneumonia. Time Taken Not Noted Log-In Date/Time: [2165-8-20] 11:18 am URINE Site: NOT SPECIFIED [Doctor Last Name ] TOP HOLD # 68398A [8-18]. FINAL REPORT [2165-8-24] URINE CULTURE (Final [2165-8-24]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. PRESUMPTIVE STREPTOCOCCUS BOVIS. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: 69 yo F with hx of psychosis/dementia, CAD, diastolic CHF, chronic kidney disease, admitted with decreased mental status most probably due to severe depression +/- catatonia . #Depressed mental status/Encephalopathy/Depression: Patient was initially admitted to the ICU. There was question of a urinary tract infection causing encephalopathy, but urine cultures were not consistent. The patient had an EEG which was unremarkable and was seen by Psychiatry who started Ativan for possible catatonia/muscle rigidity. She was transferred to the floor and all infectious workup was negative. At one point an NGT was placed because patient refused to eat or drink. Over course of hospitalization the patients mental status improved. When asked about why she was admitted she said that she was very depressed. Given that this was the 2nd admit for unresponsiveness and both times there was improvement without a cause and patient on both occasions endorsed severe depression repeat admissions for unresponsiveness should focus on treatment of severe depression +/- catatonia. She will likely benefit from a Psychiatric admission for severe depression with intermittent psychosis and catatonia if she continues to be admitted for depressed mental status. #Urinary tract infection: As noted above there was initially concern for urinary tract infection and resulting encephalopathy. However, cultures only grew yeast and empiric antibiotics were discontinued. #Chronic diastolic heart failure: Her home lasix was held initially given tachycardia but restarted on [9-12] given clinical stability. Home plavix continued however patient intermittently refused po medications. On the medicine floor, the patient's Lasix was held briefly due to decreased PO intake, but once the patient had her NGT pulled and was taking very good PO, the Lasix was restarted. Upon discharge, the patient appears euvolemic on exam. The patient was hypoxic in the unit, but responded to gentle diuresis and upon discharge, she was satting mid 90s on RA, which is her baseline. . #Diabetes mellitus: She was given sliding scale insulin. She was on Glyburide on her last admission. Will restart her on her Glyburide 5 mg PO, as well as keep her on the sliding scale. . #Depression with psychosis: Patient was seen by Psychiatry. Her initial unresponsive/catatonic episodes responded to Ativan. Her mood improved over course of hospitalization but continued to have delusions that her family is with her. She was discharged to a [Hospital 7637] rehabilitation facility . # COPD: The patient was continued on her home medications . # HTN: Her home hydralazine, amlodipine, losartan were held as pt intolerant of po intake. As her unresponsiveness continued, an NG tube was palced on [9-11] and her home medications were restarted. She was also given lasix on [9-11]. Upon transfer to the medical floor, the patient's blood pressures were stable on her home blood pressure regimen (130s the morning of discharge). . # ? recent PNA: The patient was supposedly completing a course of antibiotics for a recent pneumonia. There was no documentation this in OMR and because the course was almost over, these antibiotics were stopped while she was in the unit. . Transitional Issues: # EEG: The patient had an EEG done while inpatient as per Psych. A prior EEG showed evidence of encephalopathy. The final EEG report is still pending, please follow it up as an outpatient. Medications on Admission: Per Radius list Lasix 40mg daily Insulin aspart Quetiapine 25mg Q8H prn Ipratropium-Albuterol nebs Sodium chloride NS [Hospital1 ] Quetipaine 50mg [Hospital1 ] Metorprolol 200mg Q12H Ipratropium-Albuterol TID Polyethylene glycol 17GM daily PRN Hydralazine 10mg TID Chloecalciferol 1000 U daily Ferrous sulfate 325mg daily Calcium Carbonate 500mg TIDE Micaonzole nitrate [Hospital1 ] prn Acetaminophen 650 mg QID prn Clonidine Q7days topically Senna 2 tabs daily MVI daily Omeprazole 20mg [Hospital1 ] Losartan 100mg Daily Plavix 75 mg daily Amlodipine 10mg daily Flagyl 500mg Q8H PO daily through [9-15] Vancomycin 1G Q24H daily through [9-10] Levofloxacin 500mg daily through [9-9] Discharge Medications: 1. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. insulin lispro 100 unit/mL Solution Sig: as directed Subcutaneous ASDIR (AS DIRECTED): insulin sliding scale. 3. ipratropium-albuterol Inhalation 4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO daily PRN as needed for constipation. 5. hydralazine 10 mg Tablet Sig: One (1) Tablet PO three times a day. 6. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 7. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 8. calcium carbonate 500 mg calcium (1,250 mg) Capsule Sig: One (1) Capsule PO three times a day. 9. miconazole nitrate Topical 10. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO QID PRN as needed for fever or pain. 11. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). 12. senna 8.6 mg Tablet Sig: Two (2) Tablet PO once a day. 13. Multi-Vitamin HP/Minerals Capsule Sig: One (1) Capsule PO once a day. 14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 15. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day. 16. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 17. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 18. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day. 19. glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 20. metoprolol tartrate 100 mg Tablet Sig: Two (2) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital 671] [Hospital 4094] Hospital - [Location (un) 86] Discharge Diagnosis: primary diagnosis: urinary tract infection secondary diagnosis: coronary artery disease diastolic congestive heart failure Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname ], It was a pleasure taking care of you while you were hospitalized at [Hospital1 18]. You were brought to the hospital from your rehab center because they felt that you were acting unresponsive. You were initally admitted to the intensive care unit. You were still not interacting well and had some low grade temperatures. They sent a urine sample and they found that you had an infection in your urine. We treated the infection in your urine with antibiotics. Once you were stabilized, we were transferred to the general medicine floor. On the medicine floor, we removed your foley catheter and pulled out the tube that was placed through your nose into your stomach to help feed you. You started to eat more and you remained without a fever. Your sodium levels in your blood were a little elevated, but we started giving you more water and you improved. It is VERY important that you hydrate youself properly and drink plenty of water and other fluids. We made the following changes to your medications: START Lorazepam 0.5 mg by mouth twice daily START Glyburide 5 mg by mouth once daily STOP taking Quetiapine Followup Instructions: Please keep all follow-up appointments as below: . Department: [Hospital3 1935] CENTER When: TUESDAY [2165-9-24] at 10:15 AM With: [Location (un) 394]/[Name8 (MD) ] MD [Telephone/Fax (1) 253] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2165-9-18]	[ "348.31", "250.00", "496", "428.32", "276.0", "428.0", "414.01", "294.8", "295.72", "327.23", "403.90", "585.9", "412", "599.0", "041.4" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	13923, 14022	8171, 11421	368, 374	14190, 14190	4599, 4599	15558, 15942	3438, 3518		12399, 13900		14043, 14043		11660, 12376				14375, 15397					5735, 8148								3533, 4130																		11442, 11634		15426, 15535	2281, 2301		4144, 4580			325, 330							402, 2262				14108, 14169		4616, 5719	14062, 14087				14205, 14351						2323, 3100	3116, 3422
76,760	178,928	51519	Discharge summary	report	Admission Date: [2171-5-5] Discharge Date: [2171-5-11] Date of Birth: [2088-12-23] Sex: M Service: MEDICINE Allergies: Methyldopa / Atenolol / Codeine / Norvasc Attending:[First Name3 (LF) 530] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 82 yom with history of HTN, COPD, who presents today with shortness of breath and cough. He was in his usual state of health until 3-4 days ago when he noticed shortness of breath worse with exertion. He felt congested and was having an occasionally productive cough. He tried taking mucinex which helped somewhat but did not improve his symtpoms completely. He notes the shortness of breath is worse at night but denies orthopnea or sleeping on increased pillows. He had an admission for similar symptoms in [2169] which were attributed to a COPD exacerbation (though pt thought it was for pneumonia). He says this feels the same. He is not on home O2, just advair and combivent. He denies fevers, but did have some nightsweats over the past couple nights. . In the ED, initial vs were: T 98 BP 131/56 HR: 71 RR: 30s O2: 95-100% 3L. Patient was given albuterol/ipatropium neb and felt better but still tachypenic and cant wean of O2 (only 90%). Got solumederol prior to admission. CXR showed no pneumonia or vascular congestion. . Upon arriving to the floor, pt appears comfortable. He is tachypenic to 30 but otherwise looks well. He is very talkative and not short of breath while talking . Review of systems: (+) Per HPI (-) Denies headache . Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. . Past Medical History: -hypertension -chronic back pain -COPD -hyperlipidemia -BPH -gastritis -DJD Social History: Lives alone and is independent with ADLs. He had a recent mechanical fall with left leg bruising. He quit smoking >40 years ago. He drinks socially. No illicits. Family History: Positive for pancreatic cancer in his brother, positive for diabetes in his mother, positive for CAD in his father, positive for hypertension in his mother, positive for throat cancer in his mother, questionable stomach cancer in his sister. Physical Exam: ADMISSION EXAM: Vitals: T: 99.6 BP: 169/74 RH: 77 RR: 20 O2: 93% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated to angle of jaw, no LAD Lungs: Overall decreased air movement bilaterally with bilateral wheezes. No rales or rhonchi 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. Bruising appreciated over medial aspect of left leg Neuro: CNs [2-16] intact, motor function grossly normal Pertinent Results: ADMISSION LABS: [2171-5-5] 01:04PM BLOOD WBC-11.5* RBC-4.34* Hgb-13.4* Hct-38.9* MCV-90 MCH-30.9 MCHC-34.5 RDW-14.1 Plt Ct-165 [2171-5-5] 01:04PM BLOOD Neuts-84.4* Lymphs-10.1* Monos-4.2 Eos-0.7 Baso-0.7 [2171-5-5] 01:04PM BLOOD Glucose-110* UreaN-28* Creat-1.3* Na-141 K-4.5 Cl-102 HCO3-26 AnGap-18 . DISCHARGE LABS: [2171-5-11] 06:25AM BLOOD WBC-14.2* RBC-3.89* Hgb-12.1* Hct-34.9* MCV-90 MCH-31.0 MCHC-34.6 RDW-14.0 Plt Ct-172 [2171-5-11] 06:25AM BLOOD Glucose-113* UreaN-51* Creat-1.1 Na-143 K-4.8 Cl-104 HCO3-32 AnGap-12 . CXR [2171-5-5]: There are lucencies of the apices consistent with emphysematous change. Note is made of an azygos lobe. Chronic basilar interstitial changes are stable in appearance. The heart and mediastinum are within normal limits. Note is again made of calcification of the aortic knob. There is no pleural effusion or pneumothorax. IMPRESSION: Emphysema, with no acute thoracic pathology. . [2171-5-7] ECG: Sinus rhythm with borderline sinus tachycardia. Rightward axis. Prominent inferior lead Q waves are non-diagnostic. Modest inferior lead ST-T wave changes are non-specific. Since the previous tracing of same date sinus tachycardia rate is slower, delayed precordial QRS transition pattern is less prominent and inferior lead ST-T wave changes are decreased. . CXR [2171-5-9]: IMPRESSION: Bilateral opacifications concerning for pneumonia, unchanged since [2171-5-7]. . Micro: RESPIRATORY CULTURE (Final [2171-5-8]): MODERATE GROWTH Commensal Respiratory Flora. GRAM NEGATIVE ROD(S). SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. Brief Hospital Course: The patient is an 82-year-old man with medical history significant for COPD, presenting with shortness of breath and likely COPD exacerbation . # COPD exacerbation/pneumonia: Patient's symptoms and exam point to likely COPD exacerbation as evidenced by wheezing on exam and low O2 sats with improvement of symptoms with nebulizers. Of note, patient did have hospitalization in [2169] for COPD exacerbation. The patient did have a leukocystosis, which resolved originally, and the patient was afebrile during his hospitalization. Chest X-ray showed no sign of infiltrate. Albuterol/ipratroprium nebulizers were provided. The patient was started on prednisone 60mg daily with plan for taper. The patient was also started on azythromycin for COPD exacerbation and also in the less likely case of possible pneumonia. He was weaned within a day to room air and was saturating at the low to mid 90s. However, on HD 3, the patient developed acute respiratory distress. He was not seen to aspirate, though his CXR showed new bilateral lower lobe haziness. He was transferred to the MICU and placed on Bipap. He was empirically started on HCAP with Vanco/Cefepime/Azithro. His nebs were increased to q2prn and over the course of 1 night on Bipap improved. Serial CXR showed a worsening left lower lobe infiltrate which was likely the cause for the worsening. He was transferred back to the medical floor, where his antibiotic regimen was tailored to cefepime and azithromycin. Patient improved and was seen by Physical Therapy, who did not see the need for acute physical therapy but noted tendency to desaturate upon activity. Rehab for the continuation of antibiotics and strengthening was determined to be the best option. The patient's prednisone was planned for taper on discharge. . # [Last Name (un) ]: Creatinine at 1.3, which was stable from last year. On the day he was sent to the MICU his creatinine increased from 1.3 to 1.8. He was bladder scanned and had >450cc retained. After foley put in, his creatinine decreased, so obstructive pathology was possible. Also held ACEi and HCTZ. By discharge, the patient's creatinine had returned to baseline or below. . # Indigestion/possible GI bleed: The patient complained that his stomach felt as though he "ate something bad." His BUN is increased out of proportion to his creatinine, which suggests he may have a mild GI bleed. His hematocrit does not suggest a brisk bleed. He was placed on pantoprazole and will need follow-up. . # BPH: Continued on home terazosin therapy. Added finasteride 5 mg PO daily for urinary retention. Will need PRN straight caths until this improves. It is exacerbated by Foley trauma. . # Hyperlipidemia: Continued on home simvastatin 10mg daily. . # Hypertension: Continued on home regimen of HCTZ 12.5 mg daily, lisinopril 20 mg daily, verapamil 60mg QID until he developed renal failure. Then lisinopril and HCTZ were held because of acute kidney injury. . The patient will need outpatient follow up for possible GI bleed causing elevated BUN. Medications on Admission: -albuterol nebs qid prn sob -ipratropium nebs q6h prn SOB -Combivent 103mcg-18mcg 2 puffs QID prn sob -doxazosin 1mg po qhs -advair 250/50 1 inhalation [Hospital1 ] -hydrocortisone cream 2.5% to the rectum [Hospital1 ] for hemmorhoids -lisinopril/hctz 20mg/12.5 mg daily -simvastatin 10mg daily -verapamil 240mg ER once daily Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulozer Inhalation Q4H (every 4 hours). 2. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q4H (every 4 hours). 3. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q12H (every 12 hours) for 4 days: Continue until [2171-5-15]. 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. doxazosin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): Hold for SBP < 100. 6. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. verapamil 240 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day: Hold for SBP < 100, HR < 60. 9. lisinopril-hydrochlorothiazide 20-12.5 mg Tablet Sig: One (1) Tablet PO once a day. 10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q2H (every 2 hours) as needed for SoB/wheeze. 11. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed for SOB/wheezing. 12. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1) inhalation Inhalation twice a day. 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule 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 constipation. 15. azithromycin 500 mg Tablet Sig: One (1) Tablet PO once a day: last dose [2171-5-12]. 16. hydrocortisone acetate 25 mg Suppository Sig: One (1) Suppository Rectal [Hospital1 ] (2 times a day) as needed for hemorroids. 17. 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. 18. Lidocaine Viscous 2 % Solution Sig: One (1) Appl Mucous membrane PRN (as needed) as needed for straight cath. 19. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Primary: -Chronic obstructive pulmonary disease -Pneumonia (sputum culture with Gram negative rods). Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname 106803], You were admitted to the hospital for shortness of breath which we feel was due to an exacerbation of your COPD with probable pneumonia. We treated you with nebulizers, steroids, and antibiotics and you improved. We made the following changes to your medications: STARTED prednisone. STARTED azithromycin. STARTED cefepime. STARTED pantoprazole. STARTED finasteride. . Please follow up with your Primary Care Physician. [Name10 (NameIs) 6] appointment has been made. Once you are home, you should continue your home inhalers and nebulizers as needed for shortness of breath Followup Instructions: Department: [Hospital1 18] [Location (un) 2352] - ADULT MED When: THURSDAY [2171-5-16] at 11:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1143], MD [Telephone/Fax (1) 1144] Building: [Location (un) 2355] ([Location (un) ], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: Free Parking on Site	[ "455.3", "600.01", "724.5", "585.9", "584.9", "482.83", "272.4", "403.90", "491.21", "788.20" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	10194, 10265	4753, 7806	321, 327	10409, 10409	3092, 3092	11198, 11566	2123, 2366		8190, 10171		10286, 10388		7832, 8167				10559, 10830					3422, 4730								2381, 3073																				10859, 11175	1585, 1825					262, 283							355, 1566						3108, 3406					10424, 10535						1847, 1924	1940, 2107
55,973	127,567	4035	Discharge summary	report	Admission Date: [2182-7-9] Discharge Date: [2182-7-17] Date of Birth: [2120-10-31] Sex: F Service: MEDICINE Allergies: Penicillins / Imuran / Cephalosporins / Sulfa (Sulfonamide Antibiotics) / Reglan / Ampicillin / Lactose / Neomycin / metoclopramide / Doxepin Attending:[First Name3 (LF) 1242] Chief Complaint: Hypotension, acute anemia Major Surgical or Invasive Procedure: EGD [2182-7-15] Colonoscopy [2182-7-15] Skin biopsy [2182-7-12] Transfusion of 3U pRBCs Daily peritoneal dialysis History of Present Illness: 61 year old female with a complicated past medical history including DMI s/p pancreas transplant, CABG, NSTEMIs, CHF, ESRD s/p renal transplants, now on peritoneal HD, CHF and recent admissions for hypotension presenting with hypotension and anemia. She apparently had a hematocrit drawn earlier this week at her rehab facility and found that it was 24. On the day of admission, she asked her rehab staff to check her hct again and it was found to be 19 so she presented to the ED. At her last discharge it was discussed that she needed outpatient transfusions for chronic anemia and was supposed to start getting these beginning [7-11]. Of note, the patient reports daily nosebleeds for the last three months which wet about 3 tissues before resolution. She denies any BRBPR or melena. Stool guaiac was negative. She has chronic diarrhea but reports an increase in frequency of stooling to [7-2] time daily while at rehab which as resolved with PO vanc and loperamide. She does report new pain during stooling for the last few weeks. She denies abdominal pain at rest. Per records she has orthostatic hypotension at baseline and takes midodrine and fludrocortisone, but felt that she had worsened in the last week. She also complains of lightheadedness, fatigue, and "decreased executive functioning." She apparently has baseline low blood pressure to the 80s-90s. Of note, during her previous admission to [Hospital1 18] (d/c on [6-17]) she was treated with IVF for hypotension, and given vanc/meropenam for concern for sepsis. At this time she also had diarrhea thought to be from viral gastroenteritis which self-resolved and she was discharged to rehab. She also complains of thickening nails beginning 3 months ago and a painful purpuric rash appearing on her hads a few days ago. Dermatology has been consulted and recommended urea cream. She also complains of painless darkened elbows for around two weeks. In the ED initial VS were 99.8 70 83/48 18 99% RA. Labs notable for WBC 2.4, Hct 19.5, platelets 123, INR 2.7. Stool guaiac was negative. CXR no acute process, blood cx sent, and pt was written for transfuse 1 unit PRBC but had not received yet. BPs initially in mid 80s systolic, improved during history taking and with stimulation during exam. Given 250 mL of NS small bolus given h/o heart failure. Lactate wnl and no obvious infectious source, afebrile so did not start antibiotics. Unable to obtain peritoneal dialysis fluid in ED. Pt with 18g PIV x 2 for access. Review of systems: (+) Per HPI + dryness and pain of finger tips, discoloration of nails (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies palpitations vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies arthralgias or myalgias. (anuric w/ about 100cc/day, no urinary symptoms). Past Medical History: # Ischemic cariomyopathy/CHF; EF 35% in [4-/2182]-> 30% [5-/2182] # h/o severe MR s/p repair in [1-/2182] # NSTEMI [7-/2181], s/p [Year (4 digits) ] to LAD [9-/2181] # CABGX5 vessel [1-/2182] # s/p renal transplant ([2157]) -- c/b chronic rejection -- second renal transplant ([2160]) # s/p pancreas transplant -- with allograft pancreatectomy ([5-/2174]) -- redo pancreas transplant ([6-/2175]) -- admission for acute rejection ([7-/2180]), resolved with increased immunosupression # Diabetes mellitus type I -- c/b neuropathy, retinopathy, dysautonomia -- no longer requires regular insulin after the pancreas transplant, but has been given SS while on high-dose prednisone in house # Autonomic neuropathy # Sleep disordered breathing -- Unable to tolerate CPAP; uses oxygen 2L NC at night # Osteoporosis # Hypothyroidism # Pernicious anemia # Cataracts # Glaucoma # Anemia of CKD, on Aranesp in the past # R foot fracture c/b RLE DVT # Chronic LLE edema # Recurrent E. coli pyelonephritis # s/p anal polypectomy ([5-/2176]) # s/p bilateral trigger finger surgery ([8-/2178]) # s/p left [Year (4 digits) 6024] ([8-/2179]) Social History: Child psychiatrist, on disability. Has been in and out of hospitals in the last 9 months. Was longest at [Hospital3 ], most recently at [Hospital ] LivingCenter - [Hospital1 8218] - [Location (un) ]. Mobile with wheelchair but unable to do transfers. - Tobacco: Denies - Alcohol: Denies - Illicits: Denies Family History: Father with MI at 57. No family history of arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: INITIAL PHYSICAL EXAMINATION Vitals on transfer to floor - 97.5, 70, 97/57, 14, 98% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, left pupilary abnormality (per patient chronic) Neck: supple, difficult to assess JVP CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic murmur LSB Lungs: + crackles to mid-lung fields bilaterally Abdomen: soft, non-tender, non-distended, bowel sounds present GU: no foley [Location (un) ]: L side [Location (un) 6024], RLE with no edema DISCHARGE PHYSICAL EXAMINATION VS - T 98.4 HR 70 RR 20 BP 118/74 SaO2 100% on RA GENERAL - Chronically-ill appearing female who is resting in bed in NAD. HEENT - PEERL, EOMI. Sclera are anicteric but appear [Doctor Last Name 352]. NECK - supple, no JVD. LUNGS - Clear to auscultation bilaterally. Respirations unlabored, no accessory muscle use HEART - RRR, S1-S2 clear and of good quality. III/VI SEM heard best at LSB. No rubs or gallops. Healed midline thoracotomy [Doctor Last Name ] noted. ABDOMEN - Bowel sounds normoactive. Nontender to palpation. No masses or HSM, no rebound/guarding. EXTREMITIES - Left [Doctor Last Name 6024] present. Strong pulse in right dorsalis pedis. No peripheral edema noted. Faint pulses in bilateral radial arteries. NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [3-28] throughout, sensation grossly intact throughout. Moving all four limbs. Follows commands. Pertinent Results: CBC TREND [2182-7-17] 07:10AM BLOOD WBC-2.5* RBC-2.92* Hgb-9.5* Hct-29.3* MCV-100* MCH-32.5* MCHC-32.4 RDW-24.0* Plt Ct-PND [2182-7-16] 05:30AM BLOOD WBC-2.7* RBC-2.36* Hgb-7.8* Hct-24.9* MCV-105* MCH-33.1* MCHC-31.5 RDW-22.4* Plt Ct-79* [2182-7-15] 06:00AM BLOOD WBC-2.3* RBC-2.54* Hgb-8.7* Hct-27.2* MCV-107* MCH-34.4* MCHC-32.0 RDW-22.6* Plt Ct-94* [2182-7-14] 07:55AM BLOOD WBC-2.2* RBC-2.54* Hgb-8.6* Hct-26.8* MCV-106* MCH-34.1* MCHC-32.3 RDW-22.7* Plt Ct-82* [2182-7-13] 06:40AM BLOOD WBC-2.6* RBC-2.51* Hgb-8.3* Hct-26.1* MCV-104* MCH-33.1* MCHC-31.9 RDW-23.2* Plt Ct-87* [2182-7-12] 09:00AM BLOOD WBC-3.1* RBC-2.53* Hgb-8.5* Hct-26.1* MCV-103* MCH-33.8* MCHC-32.8 RDW-23.7* Plt Ct-93* [2182-7-11] 03:15PM BLOOD WBC-3.4* RBC-2.54* Hgb-8.6* Hct-26.1* MCV-103* MCH-34.0* MCHC-33.1 RDW-24.0* Plt Ct-85* [2182-7-11] 07:00AM BLOOD WBC-2.8* RBC-2.47* Hgb-8.3* Hct-25.2* MCV-102* MCH-33.7* MCHC-33.1 RDW-24.7* Plt Ct-91* [2182-7-11] 12:29AM BLOOD WBC-2.7* RBC-2.45* Hgb-8.4* Hct-24.8* MCV-101* MCH-34.4* MCHC-34.0 RDW-24.9* Plt Ct-103* [2182-7-10] 08:22AM BLOOD WBC-2.9* RBC-2.59# Hgb-8.7# Hct-26.4# MCV-102# MCH-33.8* MCHC-33.2 RDW-24.6* Plt Ct-101* [2182-7-9] 10:36PM BLOOD WBC-2.4# RBC-1.76# Hgb-6.1# Hct-19.5# MCV-111* MCH-34.7* MCHC-31.3 RDW-24.6* Plt Ct-123* CBC DIFFERENTIAL [2182-7-9] 10:36PM BLOOD Neuts-84* Bands-0 Lymphs-9* Monos-6 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 COAGULATION STUDIES [2182-7-10] 08:22AM BLOOD PT-26.9* PTT-34.5 INR(PT)-2.6* [2182-7-9] 10:36PM BLOOD PT-28.3* PTT-36.3 INR(PT)-2.7* [2182-7-9] 10:36PM BLOOD Ret Man-.5 ANEMIA WORKUP [2182-7-9] 10:36PM BLOOD Ret Man-.5 [2182-7-17] 07:10AM BLOOD LD(LDH)-220 [2182-7-10] 08:22AM BLOOD calTIBC-195* Ferritn-1596* TRF-150* [2182-7-9] 10:36PM BLOOD Hapto-35 OTHER LAB TESTS [2182-7-10] 08:22AM BLOOD Amylase-70 [2182-7-9] 10:36PM BLOOD LD(LDH)-212 [2182-7-10] 08:22AM BLOOD Lipase-22 [2182-7-10] 08:22AM BLOOD Albumin-2.6* Calcium-7.4* Phos-6.6* Mg-1.2* [2182-7-10] 08:22AM BLOOD tacroFK-PND [2182-7-9] 10:42PM BLOOD Lactate-1.0 [2182-7-12] 01:35PM BLOOD Cryoglb-NO CRYOGLO [2182-7-12] 09:00AM BLOOD VitB12-1062* [2182-7-10] 08:22AM BLOOD calTIBC-195* Ferritn-1596* TRF-150* [2182-7-11] 07:00AM BLOOD TSH-32* [2182-7-12] 09:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2182-7-12] 09:00AM BLOOD [Doctor First Name ]-NEGATIVE [2182-7-12] 09:00AM BLOOD PEP-NO SPECIFI [2182-7-11] 03:15PM BLOOD HIV Ab-NEGATIVE [2182-7-9] 10:42PM BLOOD Lactate-1.0 [2182-7-12] 09:00AM BLOOD VITAMIN C-PND [2182-7-11] 07:00AM BLOOD NIACIN-PND MICROBIOLOGY C. difficile PCR(Final [2182-7-11]): Negative for toxigenic C. diff MICROSPORIDIA STAIN: PENDING CYCLOSPORA STAIN: NO CYCLOSPORA SEEN FECAL CULTURE (Final [2182-7-15]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [7-14]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [2182-7-15]): NO OVA AND PARASITES SEEN. Cryptosporidium/Giardia (Final [7-15]):NO CRYPTOSPORIDIUM OR GIARDIA SEEN. HBsAg, HBsAb, HBcAb negative. [Last Name (LF) 17781], [First Name3 (LF) ] negative. GI BIOPSIES: [2182-7-15] 12:30 pm BIOPSY Site: COLON VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Pending): CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Pending): EGD ([7-15]): Ulcer in the lower third of the esophagus. Blood in the middle third of the esophagus and lower third of the esophagus. Normal mucosa in the second part of the duodenum (biopsy.) Otherwise normal EGD to third part of the duodenum. COLONOSCOPY ([7-15]): Erythema in the sigmoid colon and distal descending colon compatible with ischemic or infectious colitis (biopsy.) Normal mucosa in the cecum, ascending colon and transverse colon (biopsy.) Otherwise normal colonoscopy to cecum. DIALYSIS FLUID CULTURE: [2182-7-10] 3:18 am DIALYSIS FLUID (FINAL): 1+ PMNs. No microorganisms. FLUID CULTURE (Final [2182-7-13]): NO GROWTH. UPPER LIMB DOPPLER ([7-15]) Symmetrical velocities in the upper limb arteries as described. No hemodynamically significant stenosis in the bilateral upper limbs. TESTS PENDING AT DISCHARGE: - Vitamin C - Niacin - Zinc -Skin biopsy [2182-7-12] -Colon biopsies [2182-7-15] Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZAION ================================= 61 y.o. woman with a complicated PMH including DMI, multiple failed renal transplants now on peritoneal dialysis, s/p pancreas transplant, on immunosuppression, CHF and recent admissions for hypotension presenting with hypotension and anemia. #) ANEMIA: Acute on chronic anemia (baseline Hct ~28 but 19.5 on admission) which appears to be multifactorial due to bone marrow suppression possibly from CellCept, chronic kidney disease, pernicious anemia. and GI bleeding. On presentation, her hct appeared to have declined quickly with drop from 24 to 19 in 5 days in the setting of not getting a transfusion on [7-5] as scheduled. Initially for her management, she was transfused w/ 2 U packed RBCs. The acute possibilities for her hct drop included hemolysis, acute bleed, or progresion of her known renal disease. Hemolysis was ruled-out w/ a normal LDH, haptoglobin. Hemodynamically significant acute bleed deemed unlikely given guaiac neg, no signs of active bleeding other than epistaxis, although retroperitoneal bleed was considered since she is a dialysis patient on anticoagulation. (See below for evaluation of GI bleeding.) Her warfarin was held and is to be restarted contingent upon being epistaxis-free for >24 hours. Hypoproliferation appears to play a major role given that her reticulocyte was inappropriately normal (0.5). This was likely due to acute illness, her chronic kidney disease, and bone marrow suppression possibly due to Cellcept. Because of this, her MMF (CellCept) was held indefinitely (last given [2182-7-12]) with the approval of her transplant nephrologist. She will follow-up with Hematology the week following discharge, and potentially may require a bone marrow biopsy if her counts do not improve off CellCept. Her Epogen was also increased to 10,000 units Q MWF this admission as well. She received an additional unit pRBCs [2182-7-16] with appropriate rise in Hct. As part of the workup of her anemia, chronic diarrhea, and dysphagia, GI was consulted and performed a EGD and colonoscopy on [7-15]. Her EGD showed an ulcer in the lower third of the esophagus. Increased omeprazole to 40 mg [Hospital1 ]. Her colonoscopy showed erythema in the sigmoid colon which could be infectious vs ischemic colitis, and was biopsied. The final pathology reports of these specimins are pending at the time of discharge. Colitis felt to be ischemic in nature secondary to recurrent hypotensive episodes. #) HYPOTENSION: Her hypotension (SBPs in low 80s on presentation but runs there at baseline) was thought to be most likely due to her chronic hypotension in the setting of anemia. She also appeared to be hypovolemic in setting of her recent diarrhea, although she says her PO intake has improved. She was given 2U packed RBCs on admission, encouraged to have good PO fluid intake, and continued on her home fludrocortisone and midodrine. On transfer to the floor, she triggered for hypotension to the SBP=78 and symptomatic with lightheadedness. Her heart rate was inappropriately normal (HR=62) and she was due for her midodrine dose at the time so this was felt to be due to her autonomic dysfunction instead of representing an acute bleed. She subsequently responded to IVF rescusitation and in the days following has been hemodynamically stable. Did receive additional unit pRBCs [2182-7-16] for anemia. #) PANCYTOPENA: She presented w/ new thrombocytopenia (plt 123), worsening anemia (Hct 19.5) and leukopenia (WBC 2.4) developed since last dc on [6-17]. Likely due to her MMF or tacrolimus, and as a result her MMF (CellCept) was held indefinitely. Given immunosuppression, she is also at risk for parvovirus B19 or other marrow infiltrative process. Tacro level therapeutic at 5.1 on the day of discharge. HIV testing was negative. Hematology decided to hold off on a bone marrow biopsy until other possibilities were excluded. They will consider this as an outpatient. #) DIARRHEA: Etiology unclear. Was treated empirically for C. diff w/ PO vancomycin but PCR came back negative so this therapy was discontinued. Her home loperamide was initially held given concer for infectious diarrhea, but restarted prior to discharge. Her diarrhea resolved during the first few days of her transfer to the medical floor. Extensive stool studies, including C. diff PCR, cultures for cyclospora, cryptosporidium, giardia, salmonella, shigella, campylobacter, and ova & parasites have been negative. The microsporidia stain is pending at the time of discharge. However, following her colonoscopy and EGD she has had several loose stools. As mentioned above, she went for EGD/colonscopy on [7-15]. GI felt it was unlikely to be due to IBD. Her EGD showed an ulcer in the lower third of the esophagus. Her colonoscopy showed erythema in the sigmoid colon, likely ischemic colitis, and was biopsied. The final pathology reports of these specimens are pending at the time of discharge. #) HAND RASH: Purpuric painful papules on bilateral hands along with palmar peeling and thickened, painful nails. Seen by rheumatology and dermatology. Rheum felt it was not a vasculitis. Cryoglobolins and hep C negative. Dermatology described two problems: 1) Thick subungual hyperkeratosis and pincer nails, being treated with 40% urea cream, and 2) Recurrent palmar peeling, for which the differential etiology includes nutritional deficiencis, necrolytic acral erythema, and acrokeratosis paraneoplastica (a paraneoplastic syndrome seen with GI malignancy). Zinc, vitamin c, and niacin levels are pending at the time of discharge. Dermatology also took a biopsy, the results of which are pending. CHRONIC ISSUES ============== #) CAD: She has a h/o CAD with CABGx5 in [2-3], severe MR s/p repair [2-3] and likely ischemic sCHF with EF 30%. She was continued on ASA and atorvastatin during her admission. #) ESRD: She was continued on peritoneal dialysis, nephrocaps, lanthanum during her admission. At rehab, patient does overnight cycling with 1.5% dextrose solution. Uses two 5 L bags. Daytime dwell with 2.5% dextrose. Renal was consulted for ongoing management. #) S/P PANCREAS TRANSPLANT: On immunosuppressive therapy with MMF and tacrolimus. Held MMF (CellCept) during this admission indefinitely. She was continued on fluconazole, acyclovir, tacrolimus. She was given inhaled pentamidine for PCP prophylaxis on [7-17]. She was continued on home prednisone 5 mg QD and pancrealipase. #) ATRIAL FIBRILLATION: She was admitted in NSR on amiodarone. She was continued on amiodarone but had her warfarin held due to concern for bleed. Her warfarin will continue to be held until she is nosebleed-free for 24 hours. #) HYPOTHYROIDISM: Her TSH was found to be elevated during this admission so her levothyroxine was increased from 125 mcg to 150 mcg. She should have a TSH drawn in 6 weeks. #) GLAUCOMA: She was continued on home eye drops and methazolamide. #) GERD: Her omeprazole was increased to [Hospital1 ]. TRANSITIONAL ISSUES =================== - Please hold her Warfarin until she is nosebleed-free for 24 hours. - Please follow-up on the following lab results: microsporidium stain, zinc, vitamin c, niacin levels. - Please follow-up on the dermatology pathology results. - Please follow-up on the colonoscopy biopsy path results. - Please check TSH in 6 weeks and send results to PCP [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] (fax [Telephone/Fax (1) 3382]). - Please monitor CBC w/diff 3x/week and send results to Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in Hematology, phone [Telephone/Fax (1) 9645], fax [Telephone/Fax (1) 638]. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from nursing home records. 1. Aspirin 81 mg PO DAILY 2. Warfarin 1 mg PO DAILY16 3. Acyclovir 400 mg PO BID 4. Amiodarone 200 mg PO DAILY 5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 6. Calcitriol 0.25 mcg PO DAILY 7. Mycophenolate Mofetil 500 mg PO BID 8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES DAILY 9. Creon NF (lipase-protease-amylase) 24,000-76,000 -120,000 unit Oral TID with meals 10. Cyanocobalamin 1000 mcg IM/SC QMONTH 26th of every month 11. Epoetin Alfa 20,000 units SC QWED Start: HS 12. Fluconazole 100 mg PO QMOWEFR 13. Fludrocortisone Acetate 0.1 mg PO DAILY 14. FoLIC Acid 1 mg PO DAILY 15. Lanthanum 1000 mg PO TID W/MEALS 16. Loperamide 2 mg PO QID:PRN diarrhea 17. Artificial Tear Ointment 1 Appl BOTH EYES QID:PRN dry eyes 18. Levothyroxine Sodium 125 mcg PO DAILY 19. Atorvastatin 80 mg PO DAILY 20. Methazolamide 50 mg PO TID 21. Midodrine 15 mg PO TID 22. Nephrocaps 1 CAP PO DAILY 23. Gabapentin 100 mg PO EVERY OTHER DAY 24. PredniSONE 5 mg PO DAILY 25. Omeprazole 20 mg PO DAILY 26. Restasis NF (cycloSPORINE) 0.05 % OU [Hospital1 ] 27. Simethicone 80 mg PO QID:PRN abdominal discomfort 28. Tacrolimus 1 mg PO Q12H 29. Hemorrhoidal Suppository 1 SUPP PR TID:PRN rectal pain 30. Acetaminophen 650 mg PO Q6H:PRN pain, fever 31. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS Discharge Medications: 1. Acyclovir 400 mg PO BID 2. Amiodarone 200 mg PO DAILY 3. Artificial Tear Ointment 1 Appl BOTH EYES QID:PRN dry eyes 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 80 mg PO DAILY 6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 7. Calcitriol 0.25 mcg PO DAILY 8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES DAILY 9. Acetaminophen 650 mg PO Q6H:PRN pain, fever 10. Gabapentin 100 mg PO EVERY OTHER DAY 11. Fluconazole 100 mg PO QMOWEFR 12. Fludrocortisone Acetate 0.1 mg PO DAILY 13. Hemorrhoidal Suppository 1 SUPP PR TID:PRN rectal pain 14. Lanthanum 1000 mg PO TID W/MEALS 15. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 16. Levothyroxine Sodium 150 mcg PO DAILY Hypothyroidism 17. FoLIC Acid 1 mg PO DAILY 18. Methazolamide 50 mg PO TID 19. Midodrine 15 mg PO TID 20. Nephrocaps 1 CAP PO DAILY 21. Omeprazole 40 mg PO BID 22. PredniSONE 5 mg PO DAILY 23. Restasis NF (cycloSPORINE) 0.05 % OU [Hospital1 ] 24. Simethicone 80 mg PO QID:PRN abdominal discomfort 25. Tacrolimus 1 mg PO Q12H 26. Sodium Chloride Nasal [12-24] SPRY NU TID:PRN dry nares 27. urea NF 20 % Topical [Hospital1 ] Reason for Ordering: Per dermatology recommendations for subungual hyperkeratosis. Please apply to palms and nails and under nails. 28. Creon NF (lipase-protease-amylase) 24,000-76,000 -120,000 unit Oral TID with meals 29. Cyanocobalamin 1000 mcg IM/SC QMONTH 26th of every month 30. Cepacol (Menthol) 1 LOZ PO PRN throat pain 31. Loperamide 2 mg PO QID:PRN diarrhea 32. Warfarin 1 mg PO DAILY16 Atrial fibrillation *Please HOLD warfarin while patient has had nosebleed within 24 hours.* 33. Epoetin Alfa 10,000 UNIT SC QMOWEFR Discharge Disposition: Extended Care Facility: [Hospital ] LivingCenter - [Hospital1 8218] - [Location (un) ] Discharge Diagnosis: Primary: Acute anemia Pancytopenia Esophageal ulcer GI bleed/ischemic colitis Hypotension Secondary: End stage renal disease on peritoneal dialysis History of pancreas and renal transplant, on immunosuppression Atrial fibrillation Hypothyroidism Glaucoma 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 Dr. [Known lastname 17759], It was a pleasure taking care of you at [Hospital1 827]. You were admitted for hypotension (low blood pressure) and acute anemia, and were found to have pancytopenia (low levels of white blood cells, red blood cells, and platelets). The low cell counts may be due to your CellCept, which we stopped. You were followed by the Hematology doctors, and they will see you in follow-up next week to see if the counts are improving off the CellCept. You also underwent an endoscopy, which showed an ulcer in your esophagus. This may have contributed to your anemia as well. Your colonoscopy showed colitis, which may have been caused by your low blood pressure. They took biopsies of your colon, and results are still pending. You will see gastroenterology in follow-up. Your blood counts improved with transfusions, but you will still need close monitoring of your blood counts after discharge. You were also seen by Dermatology to evaluate the thicker, peeling skin on your hands. They took a biopsy, and results are still pending. You improved with urea cream. You will see Dermatology in follow-up. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. You received inhaled pentamidine while you were here, on [2182-7-17]. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [2182-7-23] at 9:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 647], MD [Telephone/Fax (1) 9645] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: DERMATOLOGY When: WEDNESDAY [2182-7-31] at 10:00 AM With: [Doctor Last Name 3833] [Telephone/Fax (1) 1971] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: DIV. OF GASTROENTEROLOGY When: THURSDAY [2182-8-1] at 10:00 AM With: [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [Telephone/Fax (1) 463] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage Department: TRANSPLANT When: TUESDAY [2182-9-17] at 11:00 AM With: TRANSPLANT ID [Telephone/Fax (1) 673] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: TRANSPLANT CENTER When: TUESDAY [2182-9-17] at 10:20 AM With: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage We are working on a follow up appointment for your hospitalization in Cardiology with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 171]. You need to be seen within 2 weeks of discharge. The office will contact you at home with an appointment. If you have not heard within 2 business days please call the office at [Telephone/Fax (1) 62] and ask for [Last Name (un) ].	[ "733.00", "362.01", "250.61", "428.0", "V45.81", "281.0", "276.52", "285.21", "784.7", "337.1", "V42.83", "557.9", "412", "284.19", "709.8", "008.8", "365.9", "V45.82", "E878.0", "703.8", "414.8", "250.51", "530.20", "701.1", "996.81", "E933.1", "427.31", "428.22", "585.6", "458.0", "530.81", "780.50" ]	icd9cm	[ [ [] ] ]	[ "86.11", "45.25", "45.16", "54.98" ]	icd9pcs	[ [ [] ] ]	22164, 22265	11179, 19004	428, 556	22565, 22565	6746, 11051	24079, 26064	5094, 5222		20478, 22141		22286, 22544		19030, 20455				22741, 24056													5237, 6727																11065, 11156					3126, 3526					363, 390							584, 3107											22580, 22717						3548, 4738	4754, 5078
79,396	135,144	50346	Discharge summary	report	Admission Date: [2199-10-30] Discharge Date: [2199-11-12] Date of Birth: [2145-3-27] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1835] Chief Complaint: Headache Major Surgical or Invasive Procedure: [2199-10-31] Placement of Right EVD [2199-11-4] Placement Right EVD and Posterior Fossa Craniotomy for resection of Right cerebellar lesion. History of Present Illness: This is a 54 year old woman with one year of intermittent posterior headaches and dizziness whoe was found to have a right Cerebellar mass found on MR during work up. The headaches began in the lower portion of her neck and radiate towards her occipital area. They can often radiate forwards. She also reports nausea and vomiting associated with these headaches. She does report general discoordination which has been present since her mid 30's. Past Medical History: ADD, Chronic headaches, HTN, GERD, Depression Social History: She is in graduate school. Family History: Adopted, unknown biological FHx Physical Exam: On Admission: Temp 97.3, HR 102, BP 173/126, RR 18, O2 Sat 100% Gen: Well, NAD, A&Ox3, appropriate, [Last Name (un) 664] and conversive HEENT: Pupils ERRL, EOMI 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. Language: Speech fluent with good comprehension. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [4-11] throughout. No pronator drift Sensation: Intact to light touch bilaterally. Reflexes: Brisk, symmetrical patellar reflexes Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin On Discharge: Nonfocal, incision c/d/i Pertinent Results: [2199-10-30] 06:50PM PLT COUNT-317 [2199-10-30] 06:50PM NEUTS-68.5 LYMPHS-24.4 MONOS-6.0 EOS-0.4 BASOS-0.6 [2199-10-30] 06:50PM WBC-7.6 RBC-4.79 HGB-14.2 HCT-41.9 MCV-88 MCH-29.7 MCHC-34.0 RDW-13.1 [2199-10-30] 06:50PM GLUCOSE-88 UREA N-11 CREAT-0.6 SODIUM-139 POTASSIUM-3.0* CHLORIDE-103 TOTAL CO2-22 ANION GAP-17 [2199-10-30] Brain MRI 1. A well-defined homogeneously enhancing lesion in the posterior fossa on the right side with morphology, dimensions and extent as described in the text. The image morphology is suggestive of a meningioma. It is probably arising from the posterior aspect of the right petrous temporal bone. 2. Resultant moderate dilatation of bilateral lateral ventricles and third ventricle with transependymal CSF flow. 3. Inferior tonsillar herniation. 4. No acute infarct [2199-10-31] CT head 1. Interval mild decrease of the lateral ventricular dilatation with persistent mild temporal [Doctor Last Name 534] prominence. 2. Significant mass effect from the large right cerebellar mass remains with significant cerebellar edema, effacement of the fourth ventricle, ambient and quadrigeminal cisterns and mass effect on the mesencephalon and pons and cerebellum. 3. Ascending transtentorial herniation and the descending herniation of the cerebellar tonsils filling the foramen magnum remains [2199-11-1] CXR No acute cardiothoracic process. [11-2] CT head 1. Stable position of EVD catheter. No progression of hydrocephalus. 2. Stable mass effect from large right cerebellar mass on the brainstem and occipital lobe. 3. Unchanged mild cerebellar tonsillar herniation downward. 4. No new hemorrhage, midline shift, or acute large territorial infarction. [11-4] MRI 1. Redemonstration of the large homogeneously enhancing mass lesion in the right side of the posterior fossa, unclear if this is intra- or extra-axial, with persistent mass effect on the brainstem and the cerebellar hemisphere with inferior displacement of the tonsils. 2 Ventricular catheter is noted through the right frontal approach with the tip along the medial margin of the right frontal [Doctor Last Name 534]- exact location is not well assessed on the present limited sequence study. [11-5] MRI Brain Status post resection of right posterior fossa mass with expected postoperative changes. No large area of abnormal enhancement, allowing for post-surgical change. [11-8] Head CT 1. No evidence of hydrocephalus prior to clamping of the EVD. 2. Appropriately improving post-surgical changes at the right cerebellar surgical bed. 3. Persistent mild descending cerebellar tonsillar herniation and improving right-sided ascending transtentorial herniation due to mass effect from the right posterior fossa. [11-11] Head CT 1. No evidence of hydrocephalus, unchanged ventricular size from [11-8]. 2. Persistent but improved mass effect from posterior fossa. Brief Hospital Course: Ms. [Known lastname 104953] was admitted to the [Hospital1 18] department of Neurosurgery under the care of Dr. [Last Name (STitle) ]. She had an MRI of the brain that showed a large 4.7 cm rounded lesion in the right posterior fossa, with significant mass effect on the right cerebellum, and causing leftward midline shift. She went to the OR with Dr. [Last Name (STitle) 104954] for a righrt EVD placement. She was started on Decadron with a 10mg load. Blood pressure parameter were SBP goal 100 - 140. Her drain was functioning well on [11-1] and [11-2] and she was without neurologic decline. Her drain was at 20. The drain stopped functioning on [11-2] in the pm and a CT revealed that it was not in the ventricle. It was removed and the patient has no sign of hydrocephalus on [11-3]. She was made NPO after midnight for planned resection of her lesion. On [11-4] she was taken to the operating room for posterior fossa craniotomy for resectionof her rigth cerebellar mass. While in the OR she also had a new EVD placed. She tolerated both procedures well, was extubated in the operating room and taken to the ICU post-operatively for observation and management. Her EVD was at 10cm H2O and it was well functioning overnight into [11-5] and she had no neurologic issues. A post-operative head CT was done which was unremarkable. She underwent MRI of the brain on [11-5] which showed no residual mass and persistent effacement of the 4th ventricle. Her EVD was raised to 15. On [11-6] she was transferred to the SDU and on [11-7] her EVD was raised to 20. On [11-8] she had a stable head CT and her EVD was clamped but failed her clamping trial and the EVD was opened for increased ICP's however she had no change in her clinical exam and only minor headaches. On [11-9] her ICP's transiently was greater than 20 but was asymptomatic and her EVD was clamped at 1400. On [11-11] her EVD was removed without incident following a stable head CT after beign clamped for over 24 hours and she was transferred to floor status. She was also seen by PT and OT who recommended home PT. On [11-12] she was deemed fit for discharge to home with services. She was given prescriptions and instructions for follow-up. Medications on Admission: Fluticasone 50mcg Nasal spray, Sertraline 50 QHS Discharge Medications: 1. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 2. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 5. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:10 Tablet(s) Refills:0 6. dexamethasone 1 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 6 doses. Disp:6 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Brain Tumor Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? If you have dissolvable sutures you may wash your hair and get your incision wet day 3 after surgery. You may shower before this time using a shower cap to cover your head. ?????? If your wound was closed with staples or non-dissolvable sutures then 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) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101.5?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [6-16] days for removal of your sutures and a wound check. This appointment can be made with the Nurse Practitioner. 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. ??????You have an appointment in the Brain [Hospital 341] Clinic on [11-25] at 2pm. 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. Provider: [Name10 (NameIs) ] TESTING Phone:[Telephone/Fax (1) 8139] Date/Time:[2199-11-15] 10:00 Completed by:[2199-11-12]	[ "331.3", "311", "530.81", "348.5", "401.9", "314.00", "225.2" ]	icd9cm	[ [ [] ] ]	[ "02.39", "01.51", "02.12" ]	icd9pcs	[ [ [] ] ]	8452, 8523	5440, 7719	319, 470	8579, 8579	2485, 5417	10431, 11343	1079, 1112		7819, 8429		8544, 8558		7745, 7796				8730, 10408													1127, 1127																	2440, 2466									271, 281							498, 947	1631, 2426								1141, 1409		8594, 8706						969, 1017	1033, 1062
21,776	197,813	48477+48478+48512+59098	Discharge summary	report+report+report+addendum	Admission Date: [2133-9-22] Discharge Date: Date of Birth: [2078-9-18] Sex: F Service: MICU/SICU CHIEF COMPLAINT: Acute respiratory distress syndrome (ARDS). HISTORY OF THE PRESENT ILLNESS: [Known firstname ] [Known lastname ] is a 55-year-old woman with a history of chronic obstructive pulmonary disease, prior pneumonia, with ARDS who was admitted to [Hospital6 14475] on [9-4] and transferred to the [Hospital1 69] ICU for further care. She was hospitalized here for several weeks beginning in [2132-12-18]. She, at that time, presented with dyspnea after exposure to smoke from a fire. She was subsequently found to have severe pneumonia with strep pneumococcus. this was complicated by ARDS and a very long hospital course. Since that time, she has required supplemental oxygen at home. On [9-4], the patient presented to [Hospital6 1322] with dyspnea again. She was thought to have a COPD flare and she was treated with steroids, antibiotics, and bronchodilators. She was also found to have Tylenol poisoning with elevated LFTs. She was treated with acetylcysteine. Her ventilatory status worsened and she was intubated on [9-9]. She self extubated on [9-13], but required re-intubation on [9-21], because of worsening respiratory distress. Her course was further complicated by a non ST elevation myocardial infarction with a troponin I of 5.3 on [9-8]. Subsequent echocardiogram revealed normal left ventricular function, dilated and hypokinetic right ventricle and no significant valvular disease. Her pulmonary pressures were measured as 110 by transthoracic echocardiography. She has had several episodes of both hypotension and hypertension. Extensive workup of her pulmonary process has included multiple cultures, laboratory tests, bronchoscopy and BAL, all without determining a conclusive etiology. She was recently noted to have increasing pCO2 and increasing white blood cell count; both were without clear causes. She has continued to be on a FIO2 of 0.80 at the time of transport to [Hospital1 69]. The patient was transferred here at the request of her family and healthcare proxy. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease. 2. Pneumonia/ARDS. 3. History of smoke inhalation. MEDICATIONS ON TRANSFER: 1. Zosyn. 2. Gentamicin. 3. Vancomycin. 4. Diflucan. 5. Solu-Medrol. 6. Neurontin. 7. Lactulose. 8. Protonix. 9. Albuterol. 10. Atrovent. ALLERGIES: No known drug allergies. FAMILY HISTORY: History was noncontributory. SOCIAL HISTORY: The patient works as a hairdresser. She continues to smoke at home. Her son, [Name (NI) ], lives in ..................... His phone number is [Telephone/Fax (1) 102058]. Healthcare proxy is her partner [Name (NI) 12983] [Name (NI) 102059] at the same phone number. PHYSICAL EXAMINATION: The patient is afebrile. Blood pressure 110/60, pulse 78, respiratory rate 28 on the ventilator. GENERAL: The patient is a critically-ill woman, intubated, lying in bed. HEENT: Normocephalic, atraumatic, pupils equal, round, and reactive to light, extraocular muscles are intact. Mucous membranes moist. Oropharynx clear with ET tube intact. NECK: Supple, no lymphadenopathy. LUNGS: Coarse breath sounds throughout bilaterally. CARDIOVASCULAR: Regular rate and rhythm, normal S1 and S2; 2/6 systolic ejection murmur at the lower lobe sternal border. Right ventricular lift, normal PMI, no JVD noted. ABDOMEN: Positive bowel sounds, soft, nontender, and nondistended. EXTREMITIES: Warm, no cyanosis or edema. NEUROLOGICAL: Sedated. LABORATORY DATA: Laboratory data revealed the following: White blood cell count 23.4, hematocrit 28.4, platelet count 139,000. Sodium 148, potassium 4.1, chloride 104, bicarbonate 36, BUN 21, creatinine 0.4, glucose 189, albumin 1.9, total bilirubin 0.4, ABG 7.33/70. ECG: Sinus rhythm at 90 with right atrial abnormality, right bundle branch block, anterior and inferior ST-segment depressions with T-wave inversions as well. HOSPITAL COURSE: The patient was admitted to the MICU/SICU Service. It was initially not clear whether there was truly a severe superimposed process, which was ARDS or slight worsening in a patient with already bad baseline lung disease, presumed pulmonary fibrosis and COPD. A CT angiogram of the chest was performed, which was negative for pulmonary embolus. The findings on the CT scan were otherwise, consistent with ARDS. Antibiotics were initially stopped given the lack of firm microdata to confirm an actual infection. She was given a recruitment breath and her peak was increased along with her sedation. An esophageal balloon was passed to measure pleural pressures and this was believed to be around 10. The patient began having episodes of hypotension, which were responsive to fluid boluses. As she began to have an increasing fever curve and cultures were sent, empiric antibiotics were started on [9-24], which included Vancomycin and Ceftazidime. Steroids were also continued for treatment of her COPD. The patient did not tolerated higher level of PEEP or prone positioning per ARDS protocol. The patient did have sputum with gram-positive cocci. Vancomycin and Ceftazidime were continued for an extended course given these findings. The patient also did grow yeast from the urine cultures times two. She was started on Diflucan treat this given her susceptibility to disseminated fungal infection. The patient continued to be difficult to ventilate over the course of the first several days of her admission here. She was briefly paralyzed in order to improve ventilation and some degree of permissive hypercapnea was allowed. She remained on pressure-control ventilation as the only mode of ventilation, which appeared to maintain an adequate oxygenation and high levels of FIO2 and reasonably acceptable tidal volumes in the 300 to 500 range. The Thoracic Surgery Service was consulted. They performed an open-lung biopsy [10-3]. The left lingula biopsy showed prominent septal fibrosis with organizing pneumonia with type II pneumocyte hyperplasia. No viral cytopathic effects were seen. There were no granulomas. Stains for fungi and PCP were negative. On further review with the pulmonary pathologist, very few healthy alveoli were seen on the pathology. There was extensive fibrosis with a predominance of noninflammatory cells suggesting that this may not respond to treatment with steroids. The patient continued with episodes of hypotension, which once periodically required the addition of pressor agents to maintain blood pressure. She also had episodes of tachypnea and oxygen desaturations. The patient's weaning from the ventilator appeared to be detered by levels of agitation. The patient had been on an Ativan drip for sedation and whenever the Ativan was weaned, her ventilatory status would seem to decline. She completed a two-week course of Vancomycin and Ceftazidime on [10-10]. She continued to have temperature spikes. The patient did have a declining hematocrit at one point. She did have persistently guaiac-positive stool. At one point she did pass, what appeared to be melena. NG lavage was performed and one liter of irrigated water revealed no evidence of coffee-ground.. She remained hemodynamically stable and the hematocrit remained stable after transfusions of blood. A tracheostomy was performed on [10-13]. Doppler ultrasound of the legs was performed on [10-13]. This did not reveal evidence of DVT. A formal transthoracic echocardiogram was repeated on [10-14], showing good left ventricular function, right sided hypokinesis, pulmonary artery pressures estimated at approximately 56. From a pulmonary standpoint, the patient gradually improved in her oxygenation had stabilized. The sedation was gradually tapered off and as she became more awake, the patient was switched to pressure-support ventilation rather than pressure-control ventilation. She did require very high levels of pressure support initially. However, at the current time of this dictation, the patient is down to a pressure support of 25. On [10-16], the patient had an acute decompression and desaturation to 85%. The blood gas showed a marked acidosis with a pH of 7.18, with no change in her pCO2. Given her sputum showed gram-positive cocci, Vancomycin and Ceftazidime were reinitiated for broad coverage empirically. The patient did have a temperature spike in accordance with this episode. The patient gradually defervesced from this episode and her fever curve eventually came down over the course of the next ten days. She continued on the Vancomycin, Ceftazidime for a two-week course. By the second week, the patient was afebrile with no increase in her temperature. She did again grow yeast from her urine and her Foley was changed as she was initiated on Diflucan for another 10-day course. A bronchoalveolar lavage was performed by a bronchoscopy. The BAL fluid from the second bronchoscopy showed evidence of yeast, which was not presumptively [Female First Name (un) 564] albicans. At the time of this dictation the identification of this yeast is still pending. From a neurological standpoint, it was unclear whether there had been any anoxic brain damage or evidence of stroke. It was difficult to assess given the patient was on a fairly high level of sedation on an Ativan drip. She was quite flaccid throughout, which was very concerning. The Neurology Service was consulted and following the patient. Obviously, their assessment was hindered by her level of sedation on the Ativan. However, gradually the patient was clinically improving and gradually more responsive to stimulation and her surroundings. Neurology did note that she does appear to have good brain-stem reflexes. They will continue to follow until her sedation is completely discontinued. A CT scan of the head was performed on [10-27], which showed no evidence of infarct or hemorrhage. There was no evidence for anoxic brain injury. At the time of this dictation, the patient is currently weaning gradually by small increments from her pressure support. She is also continuing to wean from her Ativan sedation. She will shortly complete a course of Vancomycin and Ceftazidime and remains afebrile at this time. She has also been hemodynamically stable for several days. Several family meetings have been held over the course of this patient's hospitalization with the patient's proxy as well as the patient's son. They have reiterated to the medical team that they believe that the patient would want to continue with aggressive measures. The family has been told on multiple occasions that the patient's overall prognosis for recovery is poor. They have been told that even if she does improve from this current episode, her functional status may require a high level of care on a long-term basis. They have also been told that it is entirely possible that Mrs.[Initials (NamePattern4) ] [Known lastname ] may be mechanical ventilator dependent for the rest of her life. At this current time, the patient will shortly be evaluated for potential rehabilitation placement. She will likely need a long-term stay in a pulmonary rehabilitation should she be deemed a viable candidate for that service. DISCHARGE DIAGNOSES: 1. Acute respiratory distress syndrome (ARDS). 2. Severe pulmonary fibrosis. 3. Chronic obstructive pulmonary disease (COPD). 4. Recurrent episodes of hypotension. 5. Yeast infection in urine. 6. Guaiac-positive stools. 7. Flaccid weakness. 8. Coronary artery disease status post small non-ST elevation myocardial infarction. 9. Status post tracheostomy and PEJ tube placement. 10. Code status: Full. DISCHARGE MEDICATIONS: 1. EPO 40,000 units subcutaneously q. Monday. 2. Aspirin 81 mg p.o.q.d. 3. Nystatin swish and swallow. 4. Sliding scale insulin. 5. Lovenox 30 mg subcutaneously b.i.d. 6. Prevacid 30 mg p.o.q.d. 7. Reglan 10 mg IV q.6h. 8. Vancomycin 750 mg IV q.12h. until [10-30]. 9. Ceftazidime 1-g IV q.8h. until [10-30]. 10. Lactulose 30 cc per PEJ tube q.8h.p.r.n. 11. Colace 100 mg per PEJ tube q.12h. 12. Fluconazole 100 mg p.o.q.d. until [11-2]. 13. Free water boluses 500 cc per PEJ tube b.i.d. 14. Albuterol and Atrovent MDI two puffs q.4h.p.r.n. 15. Tylenol p.r.n.. 16. Ativan p.r.n. 17. Morphine p.r.n. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437], M.D. [MD Number(1) 2438] Dictated By:[Name8 (MD) 16017] MEDQUIST36 D: [2133-10-29] 15:23 T: [2133-10-29] 15:29 JOB#: [Job Number 102060] Admission Date: [2133-9-22] Discharge Date: [2133-11-7] Date of Birth: [2078-9-18] Sex: F Service: ADDENDUM TO HOSPITAL COURSE: On the 17th of Decmeber the patient became increasingly febrile and tachycardic and was given boluses overnight with no improvement in her tachycardia. The patient also became increasingly febrile prompting us to send out pan culture including a urinalysis. The urinalysis ultimately revealed the patient had a urinary tract infection, so she was started on Ciprofloxacin. The urine culture ultimately grew out fungus and Diflucan was also increased. The patient continued to be tachycardic and tachypneic. An ABG was obtained while on pressure support and this revealed she was hypercarbic with a CO2 of 150 and a pH of 7.5. The patient was switched over to pressure control ventilation and ultimately assist control ventilation with resolution of her hypercarbia and acidosis. An A line was placed at that time for better monitoring. Her blood gases have been stable, but has a baseline elevated CO2 in the 50 to 60 range. The patient was also found to be hyponatremic and has been started on free water boluses. Her mental status continues to wax and wane occasionally being very alert and mildly goal directed. In general, her tone is very floppy, which is her baseline since her admission here. After hydration the patient had a hematocrit of 16. An abdominal CAT scan was obtained that revealed no bleed. Nasogastric lavage was done and was negative. The patient is persistently guaiac positive, but no bright red blood from any area. No obvious bleed. Based on this the patient was transfused and has since been stable in terms of her hematocrit. This was on the [11-4]. The patient also on prn Tylenol, Ativan, morphine, Lactulose and Combivent. Her current vent settings are assist control, 350 by 20, FIO2 of 50%. She is day three of ten of Ampicillin and Gentamycin. Current dose of Ampicillin is 2 grams q 6, Gentamycin 60 q 8 and she is on Diflucan 200 mg q.d. and will also continue that for a total of ten days. She is day three of that as well. REVISED MEDICATION LIST: Promote with fiber, Epogen 40,000 units q Monday, Prevacid 30 q.d., aspirin 81 q.d., Colace, Lovenox 30 b.i.d., Reglan 10 q 6 hours, regular insulin sliding scale, vitamin C and zinc. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 968] Dictated By:[Name8 (MD) 24764] MEDQUIST36 D: [2133-11-6] 14:29 T: [2133-11-6] 14:29 JOB#: [Job Number 102061] Admission Date: [2133-9-22] Discharge Date: [2133-11-7] Date of Birth: [2078-9-18] Sex: F Service: ADDENDUM TO HOSPITAL COURSE: On [Month (only) 1096] the 17th the patient was noted to be increasingly febrile. Cultures were sent from all locations including a urinalysis, which revealed the patient did have an elevated white blood cell count in the urine and also many bacteria. Based on this a urine culture was sent and the patient was started [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 968] Dictated By:[Name8 (MD) 24764] MEDQUIST36 D: [2133-11-6] 14:25 T: [2133-11-6] 14:27 JOB#: [Job Number 102109] Name: [Known lastname ], [Known firstname 153] Unit No: [Numeric Identifier 16477] Admission Date: [2133-4-27] Discharge Date: [2133-11-19] Date of Birth: Sex: F Service: Fenard ICU DISCHARGE SUMMARY ADDENDUM: This is a addendum to a discharge summary dated discharge date [2133-11-7]. Please note on previous discharge there was an interruption in the system so only partially dictated. Based on this a urine culture was sent and the patient was started on Diflucan. After three days of therapy with Diflucan the patient defervesced and he mental status improved. Based on that she was able to go on pressure support ventilation successfully without any problems. The patient was ultimately discharged to a nursing home with no other changes in discharge medications except for Diflucan for a total of 14 days through her G tube. [Name6 (MD) 73] [Name8 (MD) 72], M.D. [MD Number(1) 352] Dictated By:[Name8 (MD) 2512] MEDQUIST36 D: [2134-4-28] 14:52 T: [2134-5-3] 09:12 JOB#: [Job Number 16478]	[ "599.0", "112.2", "491.21", "410.71", "482.89", "515", "518.82", "578.1", "458.9" ]	icd9cm	[ [ [] ] ]	[ "99.15", "33.28", "31.1", "46.32", "96.72" ]	icd9pcs	[ [ [] ] ]							2553, 2583	11443, 11855	11878, 12910					15519, 17221																														2908, 4090												143, 2206																							2350, 2536	2228, 2325	2600, 2885
4,998	195,845	23636	Discharge summary	report	Admission Date: [2134-3-31] Discharge Date: [2134-4-12] Date of Birth: [2134-3-31] Sex: F Service: NB HISTORY: She was born to a 34 year old gravida III, para I mother, blood type A positive, antibody negative, hepatitis B surface antigen, RPR nonreactive, rubella immune. Prenatal course was notable for amniocentesis with 46XX, otherwise benign. Estimated date of confinement was [2134-4-13]. Mother presented in spontaneous labor and had a precipitous delivery with meconium stained amniotic fluid and nonreassuring fetal tracing. Infant emerged on [2134-3-31] at 2100 hours. She was suctioned below the cords and no meconium was noted. She went to the Newborn Nursery for further care. She was noted to have two cyanotic episodes and was rushed to the Neonatal Intensive Care Unit for further care. There was an epidural anesthesia. GBS was negative. No maternal fever. Rupture of membranes was 15 minutes prior to the delivery. No intrapartum antibiotics. Upon arrival to the unit the infant had three cyanotic episodes, all associated with apnea with desaturations to 58, 68 and 70 percent. No extremity movement was noted. PHYSICAL EXAMINATION: On admission weight of 3025 grams, head circumference of 34, length of 18 inches, blood pressure of 67/41 with a mean of 50. Heart rate of 150, respiratory rate of 38 to 40. In general she was active, appropriately responsive. Anterior fontanelle was open and full. Normal S1, S2 with no murmur. Breath sounds were clear. Abdomen was soft, nondistended, nontender. Extremities were well perfused. Tone was appropriate for gestational age with a normal female external genitalia. HOSPITAL COURSE BY SYSTEMS: 1. CARDIOVASCULAR: The patient has been without murmur throughout her hospitalizations and has been hemodynamically stable. Due to infarct noted on head a CT and echocardiogram were obtained on day of life number two which showed mild to moderate left ventricular dysfunction. This echocardiogram was repeated on day of life number four which showed only mild left ventricular function. She was seen by cardiology. They felt the ventricular dysfuntion was related to her antenatal event. Because it was improved, they did not need to follow her. 1. RESPIRATORY: Due to apneic spells the patient was intubated in the Neonatal Intensive Care Unit on day of life number one. She was into room on day of life number two and after having no further apneic spells she has been stable on room air with occasional O2 saturation drop to the 70s. 1. FLUID, ELECTROLYTES AND NUTRITION: Patient was initially NPO with total fluids of 80 cc per kilo per day. She was allowed to right ear lib feed until day of life number four when it was noted that she had trace guaiac positive stools as well as some flecks of blood suctioned from a nasogastric tube. At that point she was made NPO. A KUB was obtained which showed dilated loops but was otherwise unremarkable. At that point she was started on Zantac as well as antibiotics. On day of life number 5 she passed a heme negative stool and had no further blood noted from her nasogastric tube and therefore was allowed to start feeds. At the time of discharge, she was taking ad lib po feeds of BM or Similac 20 cal/oz. Her weight at discharge 3115 gram, HC 35 cm, Length 51 cm. 1. NEUROLOGIC: The patient had a CT done on day of life number one which revealed a right posterior cerebral artery infarct. She subsequently had an EEG which demonstrated seizure activity, both clinical and subclinical seizures. She was at that point loaded with phenobarbital and then started on 5 mg per kilogram per day divided B.I.D. of phenobarbital. Her most recent level was on day of life number 5 which was 40.7. She had a MRI on [2134-4-6] which was consistent with a post temporal/occipital lobe. She was discharged to home on phenobarb 12 mg po QD with a level of 32.6 taken on [2134-4-9]. She had no other clinical episodes of clinical of seizures. 1. INFECTIOUS DISEASE: The patient was initially started on ampicillin and Gentamicin for 48 hour rule out given the apneic episodes. Blood culture was negative at 48 hours and therefore antibiotics were discontinued. On day of life number four when she had these guaiac positive stools, temperature and disability, blood culture was resent. CBC was reassuring and the baby was started on ampicillin and gentamicin with a plan for 48 hour rule evaluation. The antibiotics were discontinued and she had no further infectious disease issues. The remainder of her stools were heme negative. 1. HEME: Patient had initial hematocrit of 63.4. The most recent hematocrit is on [2134-4-5] which was 59.5 She had coagulation studies done on day of life one which were normal. She had an abnormal PT PTT for which hematology was consulted. Her repeats studies PT 11.7 PTT 35.5 Fibrinogen 250, D-dimer negative. She also had a hypercoagulation evaluation. Her Antithrombin III and Protein C and Protein S level were pending at time of discharge. 1. GI: Her initial liver function studies done on day of life one ALT 30 AST 105. Her peak bilirubin was DOL #3 8.7/0.3 She had liver function studies prior to discharge AST 41 ALT 31 alk phos 195 albumin 3. CONDITION AT TIME OF DISCHARGE: Good. DISCHARGE DISPOSITION: Home PRIMARY CARE PEDIATRICIAN: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 14096] (the covering pediatrician Dr. [Last Name (STitle) 32126] phone [Telephone/Fax (1) 43144]. CARE RECOMMENDATIONS: 1. Feeds: ad lib Similac 20/breast milk 20. 2. Medications: Phenobarbital 12mg per day Trivisol 1 ml per day. 3. State Newborn Screening sent on [2134-4-3] and [2134-4-9]. 4. Immunizations: Hep B #1 given [2134-4-8]. FOLLOW UP NEEDED: 1. Neurology in [5-12] weeks at [Hospital3 1810]. 2. Follow up with the pending antithrombin III and protein C and S level in the NICU. Call [Telephone/Fax (1) 41276]. MR# [Medical Record Number 60464]. 3. Both parents should have a hypercoagulation work up. Their Primary care doctors are aware. (Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 3329] for [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ]. [Known lastname ] and Dr. [Last Name (STitle) 43313] [Telephone/Fax (1) 33581] for [Known firstname 6177] [Known firstname ] [Known lastname ].) 4. No Cardiology follow up is needed. 5. Hematology follow up is only p.r.n. DISCHARGE DIAGNOSES: 1. Right posterior cerebral artery infarction. 2. Seizures. 3. Status post rule out sepsis. 4. Mild left ventricular dysfunction. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 48738], [MD Number(1) 54936] Dictated By:[Last Name (NamePattern1) 58671] MEDQUIST36 D: [2134-4-5] 17:01:24 T: [2134-4-5] 18:00:31 Job#: [Job Number 60465]	[ "V72.1", "770.83", "V05.3", "745.5", "779.0", "V30.00", "V29.0", "763.6", "429.9", "772.4" ]	icd9cm	[ [ [] ] ]	[ "89.14", "99.55", "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]	5523, 5730							6779, 7183								5752, 6758								1722, 5500																				1206, 1694
6,014	196,119	16766	Discharge summary	report	Admission Date: [2200-12-17] Discharge Date: [2200-12-28] Service: [Hospital Unit Name 196] HISTORY OF PRESENT ILLNESS: The patient is a 78 year old man who was seen in the Emergency Room the day prior to admission for a facial rash and swelling affecting his right eye, cheek and upper lip with a diagnosis of zoster versus herpes simplex virus versus impetigo and he was sent home on Acyclovir and Augmentin. He returned on the day of admission with acute decompensation with increased shortness of breath. The patient stated that for the past two weeks he has had decreased fatigue but everything worsened the two days prior to admission. The morning of admission he felt extremely short of breath when he woke up but he denies any chest pain, abdominal pain, nausea, vomiting, fevers or chills. He also denies any changes in his diet, any lightheadedness or dizziness and no other recent symptoms. PAST MEDICAL HISTORY: 1. Diabetes, insulin dependent; 2. Peripheral vascular disease with three bypass operations; 3. History of congestive heart failure with question of diastolic dysfunction; 4. Spinal stenosis; 5. Chronic renal insufficiency; 6. Hypercholesterolemia; 7. Abnormal liver function tests; 8. Pacemaker. MEDICATIONS ON ADMISSION: 1. Isosorbide 20 mg t.i.d.; 2. Neurontin 300 mg t.i.d.; 3. Atenolol 50 mg b.i.d.; 4. Iron sulfate 325 mg q.d.; 5. Lasix 40 mg p.o. b.i.d.; 6. Zocor 10 mg q.d.; 7. Folic acid 1 mg q.d.; 8. Nephrocaps 1 tablet q.d.; 9. Insulin 30 units NPH q. AM, 4 units regular q. AM and 30 units NPH q. PM. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is retired, used to work for Pulley Production. He currently lives with his wife in [Name (NI) 4565]. He used to smoke two cigars per day for over 24 hours but quit 15 years ago. He denies any alcohol or drugs. PHYSICAL EXAMINATION: The patient's temperature on admission was 95.6 with a heartrate of 100 to 105, blood pressure 182/76, respiratory rate 30, with an oxygenation of 100% on nonrebreather, 92% on room air. On general examination he was in moderate respiratory distress. His head, eyes, ears, nose and throat examination, he had right-sided facial erythema and edema with a crusted skin, no vesicles were noted. His lungs showed wheezes, rubs and crackles at the lower bases. His cardiovascular examination showed him to be tachycardiac with a normal S1 and S2 and III/VI systolic ejection murmur at the lower left upper sternal border. His abdomen was obese, soft, and nondistended with active bowel sounds. His extremities showed 3+ pitting edema up to his knees, right side greater than the left. His right arm was also slightly more swollen than his left. On neurological examination he was alert and oriented. His cranial nerves were intact, his motor and sensory examination was grossly intact. Deep tendon reflexes were 2+ throughout. His toes were downgoing. LABORATORY DATA: Laboratory studies on admission revealed the patient's white blood cell count was 16.0 with a hematocrit of 39.8 and platelets 225. His sodium was 135, potassium 4.3, chloride 98, bicarbonate 18, BUN 69, creatinine 3.0. Glucose 170, and liver function tests were normal. Calcium was 9.1, magnesium 2.1, phosphate 4.1, initial creatinine kinase was 455 with MB of 14, admission troponin was 4.7. Electrocardiogram showed a paced rhythm tachycardiac to 110 with no clear T changes visible. Chest x-ray showed an enlarged heart with no pleural effusions, no pneumothorax but he did have diffuse opacities consistent with pulmonary edema. HOSPITAL COURSE: 1. Cardiovascular - It was felt that the patient's myocardial infarction was the cause of his dyspnea, however, it was felt that given that he was hypertensive for over three hours he just well might need to demand ischemia and he was evaluated by cardiac enzymes. His aspirin, Zocor and Atenolol were continued. He was started on a heparin drip. He was also continued on his Imdur, Lasix and Hydralazine was started for congestive heart failure. His initial creatinine kinase was 455, 520 and peak at 528 at the next creatinine kinase and then 44 and 75 before beginning to decline again. The MB peaked at 30 at next draw and troponin peaked at greater than 50. Given the severity of the patient's dyspnea and pulmonary edema, he was admitted to the CCU for diuresis. An echocardiogram was obtained which showed ejection fraction of 35%, mild symmetric left ventricular hypertrophy as well as inferior and inferolateral akinesis and skeletal right ventricular free wall hypokinesis. The patient had 2+ tricuspid regurgitation. The tricuspid regurgitation gradient was 63. Given the aortic stenosis as well as severe pulmonary hypertension the patient was taken to the Catheterization Laboratory on [12-18]. The catheterization revealed right ventricular pressures of 82/20, PA pressures of 82/23 and pressure of 31 mean. Cardiac index was 2.2. The cardiac catheterization also revealed 80% proximal right coronary artery lesion, 70% mid right coronary artery lesion and 100% right posterior lateral lesion. Given the patient's severe peripheral vascular disease the Catheterization Laboratory was unable to pass a catheter big enough for stenting and the lesions were not intervened on. Before the patient was admitted to the CCU for intensive diuresis with intravenous Lasix, as well as Nitrocort drip and high dose Hydralazine. Also on [12-18], the patient had a 16 beat run of ventricular tachycardia which was asymptomatic. The Electrophysiology Service was consulted regarding the pacer. They interrogated the pacer on [12-18] and noted 312 mode switch episodes since [2200-1-24]. The patient's fittings were adjusted to DDDR from 60 to 120 with an ADR of 140. A-V delay was set to 170 with a P-V delay of 150 and PV [Last Name (un) ] was increased to 325 milliseconds. The pacemaker was judged to be functioning adequately. The patient continued to diurese well in the CCU with 120 mg of intravenous Lasix t.i.d. as well as Nitrocort and was transferred back to the floor on [2200-12-21] for further diuresis. All of the patient's cardiac medications were continued and Nitrate was added to the Hydralazine. The Nitrocort was stopped on [12-23] and the Lasix was slowly decreased back to a p.o. dosing of 80 mg q.d. The patient underwent a repeat cardiac catheterization through the radial artery on [2200-12-22]. The stents were placed in the proximal and mid right coronary artery lesions. The patient tolerated this procedure without complications and had no chest pain at any time. The patient's cardiac enzymes remained stable and the patient's rhythm remained stable throughout the rest of the hospitalization. 2. Pulmonary - The patient was found to be have pulmonary hypertension by the initial cardiac catheterization. This was felt to be at least partially due to left ventricular failure as well as fluid overload. The Pulmonary Service was consulted. They also felt that obstructive sleep apnea could be playing a contributory role. Their recommendations include a polysomnography as an outpatient as well as potentially placing the patient on CPAP with a repeat echocardiogram to be done in the future to evaluate the pulmonary artery hypertension. The patient's respiratory status improved with continued diuresis and on the day of discharge his oxygen saturation was 95% on room air and the patient felt his breathing was at baseline. 3. On admission the patient's creatinine had been 3.0 which was slightly elevated from his baseline in the mid 2s. The Renal Service was consulted regarding the potential need for dialysis. They did not feel at this point that dialysis was warranted as the patient was improving on aggressive diuretic regimen. All the medications were dosed renally and the patient's creatinine stabilized with a value of 2.7 on the day of discharge. 4. Infectious diseases - On admission the patient was found to have a facial disease consistent with zoster as well as a likely superinfection. He had been started on Acyclovir and Augmentin in the Emergency Room. This was continued throughout the hospitalization. The Ophthalmology Service was consulted regarding a question of high involvement. They recommended Erythromycin ointment and ophthalmology follow up should the patient's lesions and/or vision not improve. The infection resolved quickly and the patient's vision improved. Augmentin was discontinued on Day #9. Also, the patient began to develop diarrhea which was found to be Clostridium difficile positive and he was started on a 14 day course of Metronidazole. The patient also developed a yeast urinary tract infection with the Foley catheter in place. On the day of removal of the Foley catheter on [12-25], the patient's urinalysis showed a white blood cell count of 417, greater than 10,000 yeast on culture. He was started on renally dosed Diflucan at 1000 mg p.o. q.d. and the patient's repeat urinalysis on [2200-12-27] showed no white blood cells, no yeast or bacteria. The patient will be discharged with instructions to finish the 14 day course of Metronidazole as well as to complete a 14 day course of t.i.d. p.o. Acyclovir. 5. Genitourinary - The patient had a Foley catheter placed during his diuresis in the CCU. The Foley catheter was discontinued on [2200-12-24]. The patient was unable to urinate on his own for the next two days. Intermittent straight catheterization revealed good urine output with an inability to urinate. This was felt likely to be due to a combination of the urinary tract infection as well as the prolonged Foley catheter placement. The Urology Service was consulted and they recommended to replace the Foley catheter after the urinary tract infection had been cleared and to discharge the patient to [State 4565] with a Foley bag at which point another attempt at removing the Foley catheter can be made. 6. Endocrine - The patient was continued on his home regimen of insulin of 30 units in the evening and 30 units NPH in the morning. Overall blood sugars were well controlled and no adjustments were made on discharge. The patient was discharged in good condition on [2200-12-28] with plans to return to [State 4565] on [12-29] and follow up with his primary care physician on [2200-12-30]. CONDITION ON DISCHARGE: The patient was in good condition. DISCHARGE STATUS: Full code. MEDICATIONS ON DISCHARGE: 1. Insulin NPH 30 units in the morning, 30 units in the evening plus 34 units of regular in the morning. 2. Lasix 80 mg q.d. 3. Imdur 30 mg q.d. 4. Flomax 0.4 mg q.h.s. 5. Flagyl 500 mg t.i.d. for ten days following discharge 6. Hydralazine 50 mg q.i.d. 7. Acyclovir 800 mg t.i.d. for four days following discharge 8. Gabapentin 300 mg b.i.d. 9. Lipitor 10 mg q.d. 10. Erythromycin ointment 0.5 inch o.d. q.i.d. for two weeks 11. Aspirin 325 mg q.d. 12. Iron Sulfate 325 mg q.d. 13. Plavix 75 mg q.d. for one month 14. Nephrocaps 1 tablet q.d. 15. Metoprolol 50 mg b.i.d. 16. Protonix 40 mg q.d. 17. Colace 100 mg b.i.d. 18. Diflucan 100 mg q.d. for 14 days 19. Guaifenesin dextromethorphan 5 mg p.o. q. 6 hours prn for cough DISCHARGE DIAGNOSIS: 1. Acute myocardial infarction 2. Congestive heart failure 3. Facial zoster 4. Acute and chronic renal failure, now resolved 5. See past medical history [First Name8 (NamePattern2) 870] [Last Name (NamePattern1) ], M.D. [MD Number(1) 5219] Dictated By:[Last Name (NamePattern1) 423] MEDQUIST36 D: [2200-12-28] 16:07 T: [2200-12-28] 17:51 JOB#: [Job Number 47369]	[ "410.71", "518.82", "250.41", "428.40", "414.01", "584.9", "416.0", "585", "E947.8" ]	icd9cm	[ [ [] ] ]	[ "88.55", "37.22", "00.13", "37.23", "88.56", "36.06", "36.01" ]	icd9pcs	[ [ [] ] ]											11329, 11765	10572, 11308	1285, 1623	3630, 10454																														1894, 3612																			145, 931																	954, 1258	1640, 1871	10479, 10546
80,156	171,470	26864	Discharge summary	report	Admission Date: [2174-2-8] Discharge Date: [2174-2-15] Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 618] Chief Complaint: Confusion. Major Surgical or Invasive Procedure: Right radial arterial line placement/removal. History of Present Illness: The pt is a 88 y/o right handed woman with a history of dementia, factor [Doctor First Name 81] def. and HTN who presented to [Hospital1 18] after her daughter found her at home (assistant living) confused. History obtained from daughter as the patient is agitated, delirious. . Per her daughter, she states that was at her baseline yesterday (baseline being, lives on her own, takes her pills on her own with some assistance by her daughter. Gets [Name2 (NI) 16429] provided but can boil an egg if needed. Cant use a microwave, gets confused. No issues with dressing herself or ambulating on her own). Last communicated with the patient around 8pm yesterday, today at 7 am she called her to remind her of her pills but got no answer. She went to her place, found her sitting, neatly dressed, but noticed to have a big bruise over the right forehead and did not recognize her daughter. [Name (NI) ] daughter was asking her questions but she looked confused and was not able to responded appropriately, meaning she was not able to answer her questions with any degree of specificity or appropriateness, but otherwise was not making any type of paraphasic errors. The patient was then taken to her room, she walked fine without trouble. But because of the continued confusion her daughter brought her in to the [Name (NI) ] herself out of concern for something wrong. On the way over the patient did complain of some nausea. . Here in the ED she was agitated and was given Zyprexa before neurologic exam. By the time of my encounter she was still agitated, restraints were placed, and she was in a hard collar. I asked her some simple questions but was only able to give me her name. She said "I don't know" when asked where she was at. I told her she was in the hospital and then she preseverated on Hospital. She would frequently yell telling me to let her go, and that her ankle hurt. She was not able to respond to any other questions for me. Past Medical History: Factor [Doctor First Name 81] def. HTN Dementia hypothyroidism osteopetrosis [Doctor First Name ] Ca Adenocarcinoma s/p resection [2168] Right eye blind. Social History: no significant etoh. no significant smoking history since [2136]. lives in [Hospital3 ] alone. she is hard of hearing, does not use aids. she is blind in right eye. Family History: Brother had stroke and DM. Mom had [Name2 (NI) 499] cancer and a stroke. Dad had MI at 65. Physical Exam: ADMISSION EXAM: --------------- Physical Exam: Vitals: T:98.9 P:82 R: 16 BP: 170/80 SaO2:99% General: Awake, combative, not cooperative. HEENT: Right forehead hematoma Neck: in M-J collar Pulmonary: Lungs CTA bilaterally in frontal fields Cardiac: RRR, Systolic murmur grade 2 Abdomen: soft, NT/ND. Extremities: No edema or deformities appreciated Skin: no rashes or lesions noted. . Neurologic: -Mental Status: Alert, oriented to self only. Was able to name parents first names. Not able to name daughter who was at bedside, or her son. [Name (NI) 66107] to "hospital", "my ankle hurts", "leave me alone". Not following any commands. . -Cranial Nerves: I: Olfaction not tested. II: Pinpoint: Right non-reactive. Left minimally reactive. + blink to threat on the right. III, IV, VI: Unable to test. cant doll maneuver because of collar V: unable to test. VII: No facial droop appreciated. VIII: Had to yell into her ears in order to get a somewhat proper response IX, X: unable to test. [Doctor First Name 81]: unable to test. XII: unable to test. . -Motor: Active resistance to movement. Seems symmetric on my exam although not formally tested. No particular slow movements noted in any one extremity. . -Sensory: + "ouch" to pinch at all four extremities. . -DTRs: unable to test. Active contraction of extremities. Ankles grade 1 bilaterally. left toe was already up before stimulation. Right was equivocal. . -Coordination: unable to test. . -Gait: unable to test. DISCHARGE EXAM PERTINENTS: Pertinent Results: LABS ON ADMISSION: ------------------ [2174-2-8] 08:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2174-2-8] 08:30AM cTropnT-<0.01 [2174-2-8] 09:00AM URINE BLOOD-NEG NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR [2174-2-8] 09:00AM URINE RBC-<1 WBC-14* BACTERIA-MOD YEAST-NONE EPI-0 [2174-2-8] 01:53PM TSH-0.60 [2174-2-8] 01:53PM [Doctor First Name 81]-3* [2174-2-8] 01:53PM THROMBN-14.4# [2174-2-8] 01:53PM PT-11.1 PTT-65.9* INR(PT)-1.0 [2174-2-8] 08:30AM WBC-7.1 RBC-3.60* HGB-11.2* HCT-32.6* MCV-91 MCH-31.2 MCHC-34.4 RDW-13.6 [2174-2-8] 08:30AM NEUTS-65.7 LYMPHS-29.2 MONOS-3.4 EOS-1.2 BASOS-0.6 [2174-2-8] 08:30AM PT-11.0 PTT-64.5* INR(PT)-1.0 [2174-2-8] 08:30AM PLT COUNT-171 . LABS ON DISCHARGE: ------------------ . IMAGING: -------- CT HEAD [2174-2-8]: IMPRESSION: 1. 4 mm of anterolisthesis of C4 on C5 and of C7 on T1 as well, potentially due to extensive degenerative changes. 2. Linear lucency through the base of an osteophyte at the level of C6 potentially an old fracture, and non displaced frature line through the left pedicle of C7. No assocaited soft tissue swelling to suggest acuity, but there is no comparison study for full assessment. MRI may offer additional detail if desired if not CI. 3. No other evidence of acute fracture or subluxation. . CXR, XR KNEE, and XR PELVIS [2174-2-8]: No acute processes including fractures. . CXR [2174-2-9]: The patient is not well positioned, which limits evaluation. Within this limitation, the cardiac silhouette appears accentuated by malpositioning. There is increased opacification along the mediastinum which appears concerning for pulmonary overload pattern. Retrocardiac atelectasis is noted. Pleural effusion cannot be excluded on the left. . CT HEAD [2174-2-9]: IMPRESSION: Severely limited study due to motion and incomplete imaging, as described above in the "Technique" section. 1. Within this limitation, the left temporal lobar subarachnoid hemorrhage appears unchanged. 2. New subarachnoid blood along the left parietal lobe may represent redistribution or new hemorrhage. . CT HEAD [2174-2-10]: Compared to study on [2174-2-8], there is no significant change in left temporal subarachnoid hemorrhage. No evidence of new hemorrhage. No significant mass effect or midline shift. . CXR [2174-2-11]: Extensive opacification in both lungs, sparing the left mid and lower lung zone has worsened since [2-9]. First consideration would be asymmetric pulmonary edema, but there could be a substantial component of pneumonia. Moderate right and small left pleural effusions have increased. Moderate-to-severe cardiomegaly is stable. No pneumothorax. . CXR [2174-2-12]: As compared to the previous radiograph, the extensive bilateral parenchymal opacities are virtually unchanged. There is slight increase in extent of a likely right pleural effusion. On the left, the retrocardiac atelectasis is constant. In addition to the pneumonia, signs of mild fluid overload are present. The appearance of the cardiac silhouette is not substantially changed. [2174-2-15] 05:25AM BLOOD WBC-8.0 RBC-3.29* Hgb-10.3* Hct-31.4* MCV-96 MCH-31.3 MCHC-32.7 RDW-13.6 Plt Ct-192 [2174-2-15] 05:25AM BLOOD PT-12.1 PTT-52.9* INR(PT)-1.1 [2174-2-15] 05:25AM BLOOD Glucose-108* UreaN-13 Creat-0.7 Na-145 K-3.4 Cl-106 HCO3-31 AnGap-11 [2174-2-15] 05:25AM BLOOD Calcium-9.2 Phos-2.8 Mg-2.0 Brief Hospital Course: The patient is an 88 yo woman h/o Factor [Doctor First Name 81] deficiency, HTN, dementia, and [Doctor First Name 499] adenocarcinoma s/p colectomy who was hospitalized due to acute confusion. She normally lives alone at an [Hospital3 ] facility and was noted to not reply to her usual morning check-in phone call by her daughter. [Name (NI) ] daughter went to her mother's house and found her dressed but otherwise inattentive and disoriented. She brought her to the ED where she was found to have a right forehead bruise. She was confused and agitated. She received a NCHCT which showed a left temporal lobe SAH, most likely traumatic. Neurosurgery was consulted but declined intervention. Neurology was consulted and admitted the patient for blood pressure management and close monitoring in the Neuro ICU as she was hypertensive and was placed on a nicardipine GTT. Hematology was consulted to assist with guiding management of the hemorrhage in the setting of her Factor [Doctor First Name 81] deficiency: Hematology recommended repletion of Factor [Doctor First Name 81] to >50% activity (her baseline was 3% prior to FFPs) with FFP and also transfusion of platelets, but based on an estimation of an increase by 20% with 10-20ml/kg of FFPs, she would require about [2161] cc of FFPs or 8 units. She was also noted to have intermittent Mobitz II AV nodal block alternating with NSR; Cardiology was consulted and noted that since she was not hypotensive, pacing would not be required. Further testing was delayed due to her severe agitation and confusion for which she was treated with Olanzapine and Lorazepam. These findings were discussed with her daughter/HCP. The patient was continued as DNR/DNI as she discussed with her PCP [Name Initial (PRE) ]. Her repeat NCHCT in the morning showed no significant changes. . When transferred to the floor, she developed a pneumonia which was treated with IV Zosyn and Vancomycin for which she still has 3 days remaining. She was seen by physical and occupational therapy for rehab screening. . When she is discharged from the rehab, she will need to be seen by Dr. [Last Name (STitle) ]. [Doctor Last Name 410] in Hematology for follow-up regarding her Factor [Doctor First Name 81] deficiency. She can schedule this appointment by calling: ([Telephone/Fax (1) 16336]. . When she is discharged from the rehab, she will need to be seen by the Electrophysiology Cardiologists for follow-up regarding her newly diagnosed second degree AV nodal heart block. She can schedule this appointment by calling: ([Telephone/Fax (1) 2037]. When she calls to request this appointment, she MUST request to see an ELECTROPHYSIOLOGIST, a special type of cardiologist. Medications on Admission: Norvasc 5 daily HCTZ 12.5 daily ASA 325 (not in her med list but her daughter said yes) oxybutynin 10mg daily Colace prn Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 2. quetiapine 25 mg Tablet Sig: 0.5-1 Tablet PO Q2000 (). 3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb treatment Inhalation Q6H (every 6 hours) as needed for wheezing/SOB. 4. ipratropium bromide 0.02 % Solution Sig: One (1) neb treatment Inhalation Q6H (every 6 hours) as needed for wheezing/SOB. 5. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Vancomycin 1000 mg IV Q 24H Course to be full 7 days. ([Date range (1) 66108]). 8. Piperacillin-Tazobactam 2.25 g IV Q6H Course to be full 7 days. ([Date range (1) 66108]) 9. oxybutynin chloride 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet PO BID (2 times a day). 10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Course to run through [Date range (3) 66109]. Discharge Disposition: Extended Care Facility: Newbridge on the [Doctor Last Name ] - [Location (un) 1411] Discharge Diagnosis: Left temporal subarachnoid hemorrhage. Urinary tract infection (enterobacter clocae). Pneumonia. Mobitz type II AV nodal heart block. Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). . Neuro exam on discharge: Waxing and [Doctor Last Name 688] mental status, exam otherwise within the limits of normal when compared to patient's baseline prior to accident. Discharge Instructions: Dear Ms. [Known lastname ], You were admitted to the [Hospital3 ] Medical Center following a fall within your home. The origin of your fall is still unknown, but may be related to the urinary tract infection you were found to have or the irregular heart rhythm you were found to be in. Either way, the fall caused you to hit your head and inside your brain, there was some bleeding called a subarachnoid hemorrhage. . At first, you were in the ICU, but when you improved, you were transferred to the regular neurology floor for care. . After someone hits their head, we watch them very closely for signs of worsened swelling or bleeding in the brain. All of your scans after the fall were relatively stable, and you made great progress with your level of alertness, memory, and physical activity in the days following the accident. . On [2174-2-11], it was noted that you were not holding your oxygen levels as high as we would like so a chest x-ray was done, and indicated that you were developing a pneumonia. We started IV antibiotics for this right away, and you improved. . Physical and occupational therapy saw you during this hospital stay, and recommended a short stay in rehab before you return to your home. At rehab, you will work to become stronger and safer on your own. Followup Instructions: Department: NEUROLOGY When: TUESDAY [2174-4-26] at 3:00 PM With: [Name6 (MD) ] [Name8 (MD) ], M.D. [Telephone/Fax (1) 2574] Building: [Hospital6 29] [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . When you are discharged from the rehab, you will need to be seen by Dr. [Last Name (STitle) ]. [Doctor Last Name 410] in Hematology for follow-up regarding your Factor [Doctor First Name 81] deficiency. You can schedule this appointment by calling: ([Telephone/Fax (1) 16336]. . When you are discharged from the rehab, you will need to be seen by the Electrophysiology Cardiologists for follow-up regarding your newly diagnosed second degree AV nodal heart block. You can schedule this appointment by calling: ([Telephone/Fax (1) 2037]. When you call to request this appointment, you MUST request to see an ELECTROPHYSIOLOGIST, a special type of cardiologist. [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] Completed by:[2174-2-15]	[ "369.60", "599.0", "V45.89", "780.09", "426.12", "294.20", "427.89", "401.9", "307.9", "V10.05", "486", "E888.9", "920", "V49.86", "041.85", "286.2", "244.9", "852.01", "V54.89" ]	icd9cm	[ [ [] ] ]	[ "38.91" ]	icd9pcs	[ [ [] ] ]	11952, 12046	7902, 10657	261, 308	12224, 12224	4341, 4346	13910, 14974	2701, 2798		10829, 11929		12067, 12203		10683, 10806				12589, 13887									3474, 4322				2860, 3213																										211, 223		5193, 7879					336, 2304		12412, 12565							4360, 5174		12239, 12393						2326, 2494	2510, 2685
67,910	105,511	52478	Discharge summary	report	Admission Date: [2106-11-4] Discharge Date: [2106-11-9] Date of Birth: [2023-2-21] Sex: F Service: MEDICINE Allergies: Ace Inhibitors Attending:[First Name3 (LF) 348] Chief Complaint: rectal bleeding Major Surgical or Invasive Procedure: Colonoscopy Blood transfusions History of Present Illness: Ms. [Known lastname ] is an 83 y/o woman with PMH notable for type 2 DM, hypertension, and recent NSTEMI who presented to the ER after several episodes of bright red blood per rectum starting last evening. The patient states that she went to move her bowels and noted bright blood in the toilet; she has a history of hemorrhoids but this typically presents as red blood on toilet tissue. She noted several more stools filling the toilet bowl with bright red blood. She also noted some clots. She noted dizziness per ED notes but denies this to me. She also reports fatigue. . On arrival to the ED, the patient's initial VS were T 98.8, HR 84, BP 156/79, RR 16, 100% on RA. On exam, there was no evidence of obvious bleeding hemorrhoid but there was bright red blood on rectal exam. Two 18 g PIVs were placed. Hematocrit was found to decrease from recent 31 --> 26 and 23. GI was contact[Name (NI) ] and their recommendations are pending. He is now admitted to the MICU for further workup. . On arrival to the MICU, the patient's first unit of PRBCs is hanging. She denies any abdominal pain, chest pain, difficulty breathing, or dizziness. She endorses some rectal pain, especially when moving her bowels last night. Past Medical History: NSTEMI (diagnosed during admission [9-1]) * DM type II (recent admit for hypoglycemia, glipizide stopped) * Mild-moderate diabetic retinopathy * HTN * Arthritis * Cataracts Social History: Patient was born in [Country ]. Moved to the United States in [2075]. Currently living with her daughter. Previously worked as a housekeeper at [Hospital 13128]. Denies tobacco/EtOH. Family History: Son in good health. Physical Exam: PE: T: 98.5 BP: 172/70 HR: 83 RR: 18 O2 98% RA Gen: Pleasant elderly female in no distress, lying in bed HEENT: no scleral icterus, L pupil large but reactive, R pupil reactive NECK: supple, JVP at 7 cm, no lymphadenopathy CV: rrr, 2/6 systolic murmur at LUSB LUNGS: clear bilaterally, no wheezing or rhonchi ABD: soft, hypoactive bowel sounds, nontender throughout EXT: warm, trace pitting edema bilateral LE, dp pulses 1+ bilaterally SKIN: no rashes NEURO: alert & oriented to self, place not oriented to time, speech somewhat difficult to understand given dentures out & accent, face symmetric, moving all extremities . Pertinent Results: [2106-11-4] 08:30AM CALCIUM-8.9 PHOSPHATE-2.9# MAGNESIUM-1.8 [2106-11-4] 08:30AM CK-MB-NotDone cTropnT-<0.01 [2106-11-4] 08:30AM CK(CPK)-44 [2106-11-4] 08:30AM estGFR-Using this [2106-11-4] 08:30AM GLUCOSE-297* UREA N-38* CREAT-1.0 SODIUM-136 POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-27 ANION GAP-11 [2106-11-4] 08:55AM freeCa-1.07* [2106-11-4] 08:55AM HGB-8.8* calcHCT-26 [2106-11-4] 08:55AM GLUCOSE-277* LACTATE-1.5 NA+-137 K+-5.4* CL--101 [2106-11-4] 08:55AM PH-7.47* COMMENTS-GREEN TOP [2106-11-4] 09:15AM PT-12.7 PTT-23.0 INR(PT)-1.1 [2106-11-4] 09:15AM PLT COUNT-240 [2106-11-4] 09:15AM NEUTS-63.6 LYMPHS-29.2 MONOS-4.3 EOS-2.9 BASOS-0.1 [2106-11-4] 09:15AM WBC-4.1 RBC-2.61# HGB-7.7# HCT-22.3# MCV-85 MCH-29.5 MCHC-34.7 RDW-13.2 [2106-11-4] 09:15AM cTropnT-<0.01 . . Colonoscopy [2106-11-8]: Diverticulosis of the whole colon Polyp in the proximal ascending colon (polypectomy) Grade 1 internal hemorrhoids Otherwise normal colonoscopy to cecum Brief Hospital Course: Ms. [Known lastname ] is an 83 year old woman with a history of diabetes, hypertension, and recent NSTEMI in setting of hypoglycemia who was admitted with multiple episodes of bloody stools. . During this hospitalization the following issues were addressed. . # GI bleeding: The pt was admitted to the MICU initially with bright red blood per rectum. In the MICU, the patient received 5 units of packed red blood cells. She was unable to tolerate a Golytely prep and was unable to have colonoscopy on [11-5]. She had an incomplete tagged RBC scan that was unable to be completed as the pt was unable to tolerate the duration of the exam. On [11-7] the pt was able to complete a Golytely prep and underwent colonoscopy on [11-8]. Colonoscopy revealed diffuse diverticulosis and one benign-appearing polyp. There was no active bleeding during the colonoscopy. The pt's hematocrit remained stable for 24 hours following colonscopy and the pt was discharged with instructions to return to the ED if she experience any additional bleeding per rectum. . # Recent NSTEMI: On the pt's recent [9-1] admission for hypoglycemia the patient had a cardiac enzyme elevation. On this admission the pt's EKG was unchanged and she had no overt symptoms of ischemia. Because of the pt's heart disease the pt was transfused with goal hematocrit of 28. The pt had negative cardiac enzymes and the pt's aspirin was discontinued due to GI bleeding. The pt was instructed not to take aspirin for 10 days following colonoscopy. . # Type 2 diabetes: The pt was monitored on sliding scale insulin during this admission. She was discharged on her home dose of metformin. . # Hypertension: The pt's beta-blocker was discontinued during this admission in order to not mask tachycardia. The pt's losartan was continued and the pt was discharged on her home dose of losartan and metoprolol. . Medications on Admission: aspirin 325 mg daily colace 100 [Hospital1 ] prn * ibuprofen prn * losartan 100 mg daily * metformin 500 mg [Hospital1 ] * toprol XL 25 mg daily * pravastatin 40 mg daily * tylenol prn * timolol 0.5% eye gtt twice daily to left eye * isopto hyoscine eye drops to left eye Discharge Medications: 1. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. 2. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day. 3. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. Glucophage XR 500 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO twice a day. 5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO once a day. 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 With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary diagnosis: Diverticulosis, gastrointestinal bleeding . Secondary diagnosis: Hypertension, diabetes Discharge Condition: Stable, able to breathe comfortably on room air, able to ambulate with walker. Discharge Instructions: You were admitted with gastrointestinal bleeding and you were found to have anemia because of blood loss. During this admission you received 5 blood transfusions and you had a colonoscopy that showed multiple diverticuli that may have caused the bleeding. You also had a small polyp that was benign-appearing that was removed. During the remainder of this admission you did not experience any more bleeding. . . All of your home medications have been continued except for aspirin. Please do not take aspirin for the next 10 days. Please take all of you other medications as directed. We have added a medication called omeprazole for stomach acid. Please take this medication every day. . . Below are your follow up appointments. Please make sure that you attend your follow up appointments as they are very important for your long-term health. . Please go to the emergency room or call your primary care doctor if you develop headaches, nausea, vomiting, weakness or numbness, are unable to tolerate food or liquids, fever > 100.4, chills, shortness of breath, chest pain, or experience any other bleeding in your bowel movements or any other concerning symptoms. Followup Instructions: Gerontology follow up: Provider [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2983] Phone:[Telephone/Fax (1) 719] Date/Time:[2106-11-11] 9:00 Primary care follow up: Provider [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10134], MD Phone:[Telephone/Fax (1) 7976] Date/Time:[2106-12-1] 2:00	[ "211.3", "401.9", "412", "362.01", "366.8", "455.0", "716.90", "250.50", "562.12", "285.1" ]	icd9cm	[ [ [] ] ]	[ "99.04", "45.42" ]	icd9pcs	[ [ [] ] ]	6684, 6741	3753, 5639	290, 323	6892, 6973	2690, 3730	8186, 8198	2010, 2031		5972, 6661		6762, 6762		5665, 5949				6997, 8163													2046, 2671									8412, 8567																	235, 252							351, 1578				6846, 6871			6781, 6825										1600, 1780	1796, 1994
80,428	176,838	20233	Discharge summary	report	Admission Date: [2192-5-26] Discharge Date: [2192-5-31] Date of Birth: [2131-1-20] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3619] Chief Complaint: Pulmonary Embolism Major Surgical or Invasive Procedure: IVC Filter History of Present Illness: Patient is a 61 yo female with PMH of metastatic ovarian CA and recently diagnosed DVT on lovenox presents with right sided CP and SOB to [Hospital1 ] [Location (un) 620] found to have a large right pulmonary artery PE and pulmonary infaract as well as several small PE's in right lower pulmonary artery as well as left lower lobe. Of note, she was seen in Heme/onc clinic on [5-16] and was found to have a RLE DVT and was started on lovenox. She received a dose of pemetrexed on [5-21] and was diagnosed with a UTI and started on ciprofloxacin. The morning of admission, she developed acute right-sided CP radiating to the right flank and right back with SOB. She presented to [Hospital1 ] [Location (un) 620] and was found to have pulmonary as above. She was started on heparin and tranferred to [Hospital1 18] for IVC filter placement. . In the ED, T 97.5 BP 94/71 HR 87 R 16 O2 sats O2 sats 99 % on RA. She received morphine 2 mg IV x1, dilaudid 1 mg IV x 3, dilaudid 2 mg IV x 1, ciprofloxacin 400 mg IV x1, zofran 4 mg IV x1 and was started on a heparin drip. She had an IVC filter placed by interventional radiology. Currently she denies CP and SOB, and her only complaint is being tired. . ROS: Denies fevers, chills, dysuria, hematuria, BRBPR, hematochezia, melena. She does report being SOB and anxious on dexamethasone which she was taking before and after her alimta. Also, she had urinary frequency over the past week prior to being started ciprofloxacin. Over the past2 months she reports weight loss and feeling exhausted doing basic ADLs. Past Medical History: Onc history: Advanced ovarian cancer orginally diagnosed in [2186] with stage IIIC, grade III papillary serous ovarian cancer s/p suboptimal debulking surgery. She received 6 cycles of carboplatin and taxol in [2187], doxil 6 cycles in [2188]. Her CA-125 began to increase and she was then started on 8 more cycles of doxil. She was then started on tamoxifen. Most recently she was started on gemcitabine of which she completed 1 cycle last dose on [4-30]. She completed radiation on [4-6]. Given that she seemed to be progressing through these therapies she received first dose of pemetrexed on [5-21]. She has mets to lungs, liver, mediastinum, soft tissue as well as bilateral hydronephrosis Iron deficiency anemia. DVT Colonoscopy in [2-/2191] with bleeding rectal mass. Biopsy inconclusive Social History: SH: Lives with husband. [Name (NI) ] smoking, ETOH, drugs. . Family History: . FH: Maternal aunt with breast cancer. No family history of ovarian or colon cancer Physical Exam: General Appearance: Thin Eyes / Conjunctiva: PERRL, Conjunctiva pale Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes : , Rhonchorous: bilateral bases R>L) Skin: Not assessed Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Pertinent Results: Imaging: CT head : 1. No acute intracranial process. 2. No evidence of edema to suggest an underlying mass lesion. However, of note, CT is not as sensitive as MR [First Name (Titles) ] [Last Name (Titles) 54340] of intracranial metastatic disease. . CTA and CT abd/pelvis: 1. LARGE CENTRAL RIGHT MAIN PULMONARY EMBOLI. THERE IS FLOW DISTAL TO THE LARGE CENTRAL THROMBUS. FAIRLY EXTENSIVE EMBOLI ARE NOTED IN THE RIGHT LOWER PULMONARY ARTERY AS WELL. Wedge shaped consolidation in right lower lobe concerning for infarctionTHERE ARE SMALL LEFT LOWER LOBE PULMONARY ARTERIAL EMBOLI. 2. FINDINGS CONSISTENT WITH DIFFUSE METASTATIC DISEASE WITH NUMEROUS METASTASIS THROUGHOUT THE LIVER. MEDIASTINAL AND HILAR ADENOPATHY AND A LARGE RIGHT LOWER QUADRANT PELVIC MASS. 3. DELAYED EXCRETION WITHIN THE RIGHT KIDNEYS WITH SEVERE HYDRONEPHROSIS AND CORTICAL THINNING. THE OBSTRUCTION OF THE RIGHT KIDNEY IS BEING CAUSED BY THE RIGHT LOWER QUADRANT PELVIC MASS. 4. CHOLELITHIASIS. 5. SIGMOID DIVERTICULOSIS. 6. MILD ANASARCA AND MILD ASCITES . CXR [2192-5-27] - The cardiac size is within normal limits. Tortuous aorta is present. Left lung is clear. Some opacities are present within the right lower lobe which would be more characteristic for aspiration pneumonia than for pulmonary embolus. The known pulmonary metastases are not positively identified. IMPRESSION: Opacities in right lower lobe not particularly characteristics for pulmonary embolus. . [2192-5-26] 09:50AM WBC-5.2 RBC-2.76* HGB-8.7* HCT-25.3* MCV-92 MCH-31.4 MCHC-34.3 RDW-16.0* [2192-5-26] 09:50AM NEUTS-93.2* BANDS-0 LYMPHS-5.8* MONOS-0.3* EOS-0.4 BASOS-0.2 [2192-5-26] 09:50AM PLT SMR-NORMAL PLT COUNT-195 [2192-5-26] 09:50AM PT-14.2* PTT-70.5* INR(PT)-1.2* [2192-5-26] 09:50AM GLUCOSE-117* UREA N-22* CREAT-1.1 SODIUM-136 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-19* ANION GAP-17 [2192-5-26] 09:50AM CALCIUM-8.7 PHOSPHATE-3.2 MAGNESIUM-2.3 [2192-5-26] 11:30AM URINE RBC-0-2 WBC-[11-1]* BACTERIA-MANY YEAST-NONE EPI-0-2 [2192-5-26] 11:30AM URINE BLOOD-NEG NITRITE-POS PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR [2192-5-26] 11:30AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.045* [2192-5-30] 05:40AM BLOOD WBC-5.7# RBC-3.11* Hgb-9.5* Hct-27.9* MCV-90 MCH-30.6 MCHC-34.1 RDW-15.8* Plt Ct-68* [2192-5-28] 06:50AM BLOOD WBC-1.4# RBC-2.59 Hgb-8.0* Hct-24.4* MCV-94 MCH-30.9 MCHC-32.8 RDW-15.5 Plt Ct-121* [2192-5-31] 06:45AM BLOOD Neuts-75* Bands-2 Lymphs-11* Monos-11 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [2192-5-31] 06:45AM BLOOD Plt Ct-56* [2192-5-28] 06:50AM BLOOD PT-14.8* PTT-77.9* INR(PT)-1.3* [2192-5-26] 09:50AM BLOOD PT-14.2* PTT-70.5* INR(PT)-1.2* [2192-5-26] 11:03PM BLOOD PTT-60.5* [2192-5-31] 06:45AM BLOOD Glucose-85 UreaN-12 Creat-0.7 Na-136 K-4.0 Cl-104 HCO3-22 AnGap-14 [2192-5-27] 05:32AM BLOOD Glucose-91 UreaN-16 Creat-0.8 Na-133 K-4.1 Cl-105 HCO3-18* AnGap-14 [2192-5-31] 06:45AM BLOOD Calcium-9.1 Phos-1.9* Mg-2.0 [2192-5-26] 09:50AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.3 [2192-5-26] 11:30 am URINE Site: CLEAN CATCH FINAL REPORT [2192-5-28] URINE CULTURE (Final [2192-5-28]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ 16 I AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 16 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: A/P: 61 yo female with metastatic ovarian cancer with recently diagnosed DVT now with large right main pulmonary artery PE and pulmonary infarct and small bilateral lower lobe PEs despite anticoagulation with lovenox now s/p IVC filter placement . # PE: The patient presented with a large R main pulmonary artery PE despite lovenox therapy. Upon arrival to [Hospital1 18] the pt was taken to IR for placement of an IVC filter. She was started on a heparin gtt and transfered to the ICU for monitoring given her large clot burden. The pt remained HD stable overnight and was transferred to the medical floor. There she remained stable on room air. After another 24 hours, she was transitioned back to lovenox which she will continue indefinitely. She was evaluated by physical therapy and after several sessions, it was felt that she was strong enough to return home with continued PT at home. . # UTI: The pt was started on cipro on [5-22] for UTI, but urine culture reveals e. coli resistant to cipro. UA still grossly positive and has hydronephrosis which has been noted in the past. She was transitioned to ceftriaxone. Concern was given to the development of pyelonephritis as the pt has known b/l hydronephrosis. She has no current evidence of systemic toxicity with no fevers and normal WBC. Her WBC cound dropped briefly to the neutrapenic range, during which time she was transitioned to cefepime. After her WBC count recovered with Neupogen and sensitivities returned she was transitioned to Bactrim to complete an anticipated 10 day total course. . # RUQ pain: The patient was also noted to have a RLL pulmonary infarct on CTA which was causing her signficant pain with motion and deep breathing. This was treated with PO dilaudid to good effect. The pain was improving throughout admission. . # Anemia: Known iron deficiency anemia. Her HCT drifted slowly down during this admission, likely due to Gemzar. She received a total of 2 units of PRBCs to good effect. . # Nausea: Seems to have this at baseline. Ativan with best effect. Continued home ativan as well as PRN compazine and zofran . # Metastatic ovarian CA: Has widely metastatic disease. Currently receiving alimta. She will follow up with her primary oncologist regarding further treatment. . # FEN: regular diet . # Code: Spoke with patient and her husband and [Name2 (NI) 41859]. The patient did not have a HCP prior to admission, but identified her husband as the person who would be her HCP. She was givne the HCP form to sign. Additionally, we discussed her wishes, and she said "I haven't hought about this." She knows that "I would not want to be kept alive dependent on machines." However, she does say that she would want to give it a try for now. I explained that is she got intubated that it would most likley be for worseing of her PE, which would be very grave and she would likely not recover from this. She "wants to think about it." For now, she is full code. . Medications on Admission: Medications: Ciprofloxacin 500 mg PO twice a day (started in [5-22]) Enoxaparin 60 mg SC twice a day Lorazepam 0.5 mg Tablet [12-14] Tablet(s) by mouth every 4 hours as needed for nausea/ insomnia Folic Acid 0.8 mg PO daily Iron 325 mg PO every other day Loperamide [Imodium A-D] 2 mg Tablet 1 Tablet(s) by mouth as needed for diarrhea Multivitamin Omega-3 Fatty Acids [Fish Oil] 1,000 mg Capsule 1 Capsule(s) by mouth daily Discharge Medications: 1. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. Disp:30 Tablet(s) Refills:0 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for diarrhea. Disp:60 Tablet(s) Refills:2 7. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 8. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:30 Tablet(s) Refills:0 9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 10. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Pulmonary Embolus E.coli Urinary tract infection Metastatic ovarian cancer Discharge Condition: All vital signs stable, afebrile, ambulatory Discharge Instructions: You were admitted with a clot in your lungs called a pulmonary embolus. You had a filter placed in your inferior vena cava to protect you from these in the future. You were started on IV blood thinners in the hospital and transitioned to the blood thinner called Lovenox that will be administered by a shot twice a day. You will continue this medication until your oncologist says you should stop. The pain on your right side is associated with the blood clot and should continue to get better. We will prescribe a medication called Dilaudid for you to take at home to help the pain. You were also found to have a urinary tract infection. This was treated with IV antibiotics intitially and then you switched to oral antitiotics. You will need to continue to take these antibiotics (Bactrim or Trimethoprim/Sulfa) for several more days to finish up treatment. Please take all your medications as prescribed and make all of your follow up appointments. Please call your doctor if you experience any symptoms that are concerning to you. Followup Instructions: Provider: [First Name8 (NamePattern2) 2295] [Last Name (NamePattern1) 10917], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2192-6-4] 10:30 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2192-6-11] 4:00 Provider: [First Name8 (NamePattern2) 2295] [Last Name (NamePattern1) 10917], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2192-6-11] 4:30 [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 3621]	[ "787.02", "041.4", "591", "415.19", "V16.3", "593.4", "V12.51", "197.7", "183.0", "280.9", "599.0" ]	icd9cm	[ [ [] ] ]	[ "99.04", "38.7" ]	icd9pcs	[ [ [] ] ]	12122, 12180	7617, 10586	334, 346	12300, 12347	3551, 7594	13433, 14008	2913, 3000		11069, 12099		12201, 12279		10612, 11046				12371, 13410													3015, 3532																										276, 296							374, 1966																	1988, 2813	2829, 2897
10,642	174,626	46154	Discharge summary	report	Admission Date: [2195-2-24] Discharge Date: [2195-3-6] Date of Birth: [2136-3-15] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 5827] Chief Complaint: fever and MS change Major Surgical or Invasive Procedure: none. History of Present Illness: This is a 58yoW with h/o end-stage multiple sclerosis, s/p total colectomy [11/2194], transferred from [Hospital3 2558] with mental status change, tachycardia 140bpm, and T 102. She is non-verbal at baseline but communicates by head nod. On arrival to [Hospital1 18] ED vitals 101.8, 139, 130/70, 22, 95%RA. Initial lactate 3.0. She received 6L NS and LR in the ED and was treated with levofloxacin/vancomycin/metronidazole. She c/o abdominal pain that was sharp and constant (with prompting in questioning). She c/o nausea but denied vomiting. CT abdomen/pelvis showed no acute intraabdominal pathology. BP normalized with SBP 120s, and she was admitted to the floor. . Soon after arrival to the medical floor her SBP dropped to 80s, HR 110s. She received additional 3L NS. ABG 7.39/40/74 with lactate 0.8. She continued to c/o abdominal pain, pointing to pelvic region. Blood pressure normalized 120s/70s, however, she became more tachycardic with HR 120s. She was transferred to the unit where she was treated with aztreonam for urosepsis. . On presentation she nods yes to abdominal pain, denies headache, chest pain, shortness of breath. Past Medical History: # Multiple sclerosis, dx [2176]. Her decline has only been in the past 18 months. She went from fully communicative before to nonverbal now. She was ambulating independently but started using a cane, then a walker, and is now bedbound. # s/p total colectomy + colostomy for "compaction and infection," [11/2194] (at [Hospital1 756] and Women Hospital) # UTI [10/2194] # depression/mood disorder # anxiety # hepatitis C # hepatitis B # optic neuritis # dysphagia . Social History: lives at [Hospital3 2558]. Friends in the community serves as her HCP Family History: not known (patient nonverbal) Physical Exam: VITALS: Tm/c 99.3 HR 109 BP 91/61 SBP 91-113 RR 24 97%RA GEN: anxious, grimacing at times during PE, nodding appropriately to yes/no questions Skin: no rashes, + RLE heel skin breakdown HEENT: PERRL, anicteric, OP clear, MMM Neck: supple, no LAD, JVP flat CV: tachy, regular, no mrg Resp: CTAB, no crackles, sl [Month (only) ] at bases, transmitted upper airway sounds Abd: +BS, soft, + ttp suprapubically, no rebounding/guarding, G-tube, ileostomy bag Ext: warm, well-perfused, contracted arms and legs, no edema, 1+ DP pulses B/l Neuro: alert, appropriate, CN II-XII intact, can move BUE/BLE with min arm movement and minimal toe wiggling, contracted with increased tone, 2+-3 B/l biceps reflexes. + pain with leg movement b/l (stable per nurse) Pertinent Results: [2195-2-24] 02:52AM LACTATE-3.0* [2195-2-24] 03:00AM PLT COUNT-473* [2195-2-24] 03:00AM NEUTS-65.7 LYMPHS-26.1 MONOS-5.9 EOS-0.2 BASOS-2.1* [2195-2-24] 03:00AM WBC-17.2* RBC-4.62 HGB-15.1 HCT-45.5 MCV-98 MCH-32.7* MCHC-33.2 RDW-13.3 [2195-2-24] 03:00AM LIPASE-18 [2195-2-24] 03:00AM ALT(SGPT)-32 AST(SGOT)-44* ALK PHOS-72 AMYLASE-59 TOT BILI-0.4 [2195-2-24] 03:00AM GLUCOSE-105 UREA N-24* CREAT-0.4 SODIUM-140 POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-25 ANION GAP-18 [2195-2-24] 04:03AM PT-11.8 PTT-24.7 INR(PT)-1.0 [2195-2-24] 04:43AM URINE RBC-0 WBC-0-2 BACTERIA-MANY YEAST-NONE EPI->50 [2195-2-24] 04:43AM URINE BLOOD-TR NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-MOD [2195-2-24] 04:43AM URINE COLOR-Yellow APPEAR-Cloudy SP [Last Name (un) 155]-1.013 [2195-2-24] 06:51AM URINE MUCOUS-FEW [2195-2-24] 06:51AM URINE 3PHOSPHAT-MOD AMORPH-FEW [2195-2-24] 06:51AM URINE RBC-[7-12]* WBC-[4-6] BACTERIA-MOD YEAST-NONE EPI-<1 RENAL EPI-[4-6] [2195-2-24] 06:51AM URINE BLOOD-SM NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-9.0* LEUK-MOD [2195-2-24] 06:51AM URINE COLOR-Yellow APPEAR-Cloudy SP [Last Name (un) 155]-1.028 [2195-2-24] 09:15AM NEUTS-58.7 LYMPHS-36.9 MONOS-3.6 EOS-0.3 BASOS-0.5 [2195-2-24] 09:15AM WBC-11.9* RBC-3.46# HGB-11.7# HCT-34.0# MCV-98 MCH-33.8 MCHC-34.4 RDW-13.6 [2195-2-24] 09:23AM LACTATE-1.4 . CXR [2-24]: Right diaphragmatic elevation with bibasilar atelectasis. An underlying consolidation is not excluded, and dedicated PA and lateral chest x-ray is recommended. . CXR [2-25]: unchanged from prior CXR [3-1]: Some right basilar atelectasis is demonstrated, but no definite new infiltrate is seen. Fluid status is within normal limits and unchanged. Cardiac silhouette is normal. . [2-24] CT Abd/Pelvis: IMPRESSION: 1. No evidence of acute inflammatory process within the abdomen or pelvis. Status post total colectomy with right lower quadrant ileostomy. 2. Bibasilar airspace disease, likely atelectasis. 3. Left adrenal nodule, not completely characterized on this examination, further evaluation with dedicated adrenal CT or MRI is recommended. 4. Right hepatic hypodense lesion, too small to characterize. . LE USN: No evidence of lower extremity deep vein thrombosis, bilaterally. . RUQ USN: Sludge and stones identified within the gallbladder. No evidence of cholecystitis or biliary dilatation. . [2-27] Abd/Pelvic CT: 1. No significant change from study performed three days prior, with no new acute inflammatory process within the abdomen or pelvis identified. 2. Small bilateral pleural effusions with associated segmental atelectasis, right greater than left. 3. Nodular appearance of left adrenal gland again not completely characterized on this CT. 4. Unchanged small hypoattenuating lesion within the liver. 5. Tiny pulmonary nodule within the right lung. In the absence of malignancy, followup imaging within a year would be recommended to document stability. . abd XR:No evidence of obstruction or free intraperitoneal air. Left basilar atelectasis. Brief Hospital Course: This is a 58yo woman with end stage multiple sclerosis presenting with hypotension, tachycardia, fever, abdominal pain, and mental status change which was diagnosed as urosepsis who is s/p MICU stay, now on meropenem. . 1. Fever, hypotension, and MS change: The patient's fever, hypotension, and MS change were thought to be secondary to urosepsis given her + UA. She had an elevated lactate on admission and quickly became hypotensive. She was transferred to the MICU, fluid resuscitated, and continued on levofloxacin/vancomycin/metronidazole which was then changed to Aztreonam given her allergy history when her UA came back positive for proteus. A CXR was obtained and was concerning for pneumonia vs atelectasis. However, given no h/o cough, sputum production, chest pain, or SOB, or oxygen requirement, this finding was attributed to atelectasis. The ddx also included adrenal insufficiency since patient likely treated with steroids for MS flares, and autonomic disregulation given h/o central neurologic degenerative disease. A cortisol stimulation test was preformed with a bump in cortisol level of only 6. However, at this point the patient's hypotension had improved while on empiric antibiotics. Urine and blood cx were negative. The patient was hemodynamically stable with decreasing leukocytosis and was transferred to the floor. She spiked with a bump in her WBC ct and her coverage was broadened to meropenem and vancomycin. She subsequently defervesced and her leukocytosis resolved. She remained afebrile for > 48 hrs and vanco was discontinued. She remained afebrile for an additional 48 hrs and the patient was deemed well enough to be discharged on an additional 7 day course of IV meropenem. The PICC line is ready to use and may be pulled after completion of her 7 day course of meropenem. . 2. Tachycardia: the patient remianed in sinus tachycardia througout the duration of her hospitalization. The differential included anxiety, pain, resolving hypotension/infection, and PE. Given the patients abd pain, pain seemed a plausible etiology. LENIs were obtained which were neg for PE and the pt did not have an O2 requirement. Her tachycardia improved during the duration of her hospitalization. . 3. Abd pain: The patient complained of persistent abdominal pain throughout the course of her hospitalization. She had two CT of abd/pelvis which were negative for obstruction, colitis, pancreatitis, or abcess. Her LFTs were unremarkable. She was stooling well through her ostomy. C diff was negative x 2. As the patient had some skin breakdown around her ostomy site, this was proposed to be the cause of her pain. She was also started on Reglan with the thought that gastric motility may have been affected, causing her abdominal pain and nausea. Also, the epigastric location of her pain makes PUD a possible etiology. Her PPI was increased to [Hospital1 ] and her abdominal pain resolved despite continued TTP upon exam. . 4. MS: The patient has end stage MS. she was continued on Copaxone and Baclofen per her outpt regimen. Medications on Admission: amitrytyline 50mg HS calcium vitamin D fluticasone 50mcg 2 sprays daily mvi valproic acid 250mg/5mL syrup, 13mL [Hospital1 ] colace 100 [Hospital1 ] neurontin 300 tid metoprolol 12.5 tid tylenol 650 q6 baclofen 5 qhs oxycodone 5 q6H prn prilosec 20mg daily Copaxone 20mg SC daily Discharge Medications: 1. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2) Spray Nasal DAILY (Daily). 5. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY (Daily). 6. Valproate Sodium 250 mg/5 mL Syrup Sig: Thirteen (13) ml PO Q12H (every 12 hours). 7. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 8. Gabapentin 250 mg/5 mL Solution Sig: Three Hundred (300) mg PO TID (3 times a day). 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six (6) hours. 11. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at bedtime)). 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 13. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 14. Glatiramer 20 mg Kit Sig: One (1) Kit Subcutaneous DAILY (Daily). 15. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg Intravenous every six (6) hours for 7 days. 16. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: urosepsis Discharge Condition: Improved. BP stable and pt afebrile. Discharge Instructions: Please return to the ER or call your PCP if you experience increasing temperatures, change in mental status, or any other symptoms that are of concern. Followup Instructions: Please follow up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 5351] [Telephone/Fax (1) 608] upon discharge. Completed by:[2195-3-6]	[ "V44.3", "787.2", "599.0", "038.49", "995.92", "070.30", "070.70", "276.2", "789.06", "340", "V45.3", "377.30", "V49.84", "784.3" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.6", "97.03" ]	icd9pcs	[ [ [] ] ]	11016, 11086	6202, 9267	314, 322	11140, 11179	2963, 6179	11380, 11548	2129, 2161		9605, 10993		11107, 11119		9293, 9582				11203, 11357													2176, 2944																										255, 276							350, 1517																	1539, 2020	2036, 2113
7,445	107,485	51118	Discharge summary	report	Admission Date: [2188-4-12] Discharge Date: [2188-4-30] Date of Birth: [2110-3-15] Sex: M Service: MEDICINE Allergies: Penicillins / Cephalosporins / Pravachol / Zestril / Beta-Adrenergic Blocking Agents Attending:[First Name3 (LF) 41017] Chief Complaint: Respiratory failure Major Surgical or Invasive Procedure: Intubation/extubation History of Present Illness: 78 y/o M w/complicated med hx who was in his USOH this evening when his granddaughter found him downstairs confused, gasping for breath, and "shaking". His daughter ran down there and she wasn't sure if he was seizing or not. He is on 1-2L home O2 at baseline, and per the daughter his o2 sat is usually between 90-92%. His O2 sat at that time was in the 70s and per the daughter he had rales to the apex on the left. She gave him lasix 40 po and called EMS. When they arrived, he was in respiratory distress, with bp 190/110, p 135, rr 36, 86% on an unclear amt of oxygen. His FS was initally 90, the daughter gave him some glucose tablets, and it went down to 75. EMS gave him lasix 80 mg iv, an amp of D50 and brought him here. While en route, he vomited in the ambulance and aspirated. . In the ED, he was febrile to 103.8, tachycardic in the 110s-130s, tachypneic in the 30s-40s. He was 84% on NRB and was intubated. He was started on a nitro gtt and propofol, but became hypotensive to the 70s/50s and the nitro was discontinued. He had 825 cc UOP while downstairs. He also received etomidate 20 mg iv, succinylcholine 120 mg iv, aspirin 600 mg pr, tylenol, and levofloxacin 500 mg iv. Post-intubation he had no difficulties oxygenating, and he was transferred upstairs to the MICU. . On review of systems with his daughter, he had been in his USOH earlier today, running errands. Because he is on home O2 and has a poor pulmonary baseline, he does not walk far, but this had not been getting worse recently. He did recently finish Pulmonary Rehab at the [Hospital1 ] which was not helpful. He had not c/o chest pain, SOB, cough, weakness, vomiting, or abd pain. His daughter thinks he has chronic abd pain from his diabetic neuropathy but that he describes this as nausea, although he hadn't been vomiting. Of note the pt's wife, who lives at home with them, has bronchitis and is on abx. . Past Medical History: 1. CHF w/EF 20% in [2183] (this was prior to cath) - daughter reports he has worsening LVH 2. CAD s/p RCA stent [2183] 3. Lung ca s/p R pneumonectomy [2180], s/p chemo, no XRT 4. chronic pancreatitis 5. Type 2 DM on insulin, w/severe neuropathy (?autonomic) 6. gastritis 7. s/p ccy 8. HTN 9. MGUS 10. hx of flash pulmonary edema requiring intubation Social History: Retired engineer, worked for NASA and [Hospital6 ]. Lives at home with his wife, daughter, and daughter's family. Hx smoking quite a bit but quit 35 yrs ago. Hx asbestos exposure (worked in shipyards). Family History: DM, CAD Physical Exam: Tmax: 103.8 (rectal) Tc: 99.8 BP: 90/56 (MAP 67) P: 98 Vent: AC 0.6 450x16 (23) 5 spo2 98% PIP 25 Plat 20 Gen: intubated/sedated, doesn't open eyes to voice or pain but occasionally wakes up and grimaces HEENT: anicteric, perrl (2 mm -> 1mm) Neck: supple, JVD approx 7-8 cm Lungs: decreased breath sounds on R, diffuse rhonchi on left CV: tachycardic, regular, no murmurs but diff to appreciate above lung sounds Abd: soft, nt/nd. +bs. Ext: no edema, feet cool, 1+ dp bilaterally Pertinent Results: LABS on admission: WBC 8.4, Hct 38.2, MCV 93, Plt 228 (DIFF: Neuts-79.0* Bands-0 Lymphs-12.3* Monos-5.1 Eos-2.9 Baso-0.8) PT 13.5, PTT 25.7, INR 1.2 Na 134, K 6.5, Cl 98, HCO3 28, BUN 24, Cr 1.2, Glu 104 Ca 9.0, Phos 2.5, Mg 1.6 . VBG 7.33/61/35/34 . [2188-4-12] 1:00AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.009 Blood-NEG Nit-NEG Prot-NEG Glu-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG . [2188-4-11] 11:40PM CK(CPK)-177* CK-MB-4 cTropnT-0.01 [2188-4-12] 07:26AM CK(CPK)-213* CK-MB-7 cTropnT-0.03* [2188-4-12] 02:02PM CK(CPK)-243* CK-MB-7 cTropnT-<0.01 [2188-4-18] 04:00AM CK(CPK)-282* CK-MB-2 cTropnT-<0.01 [2188-4-13] 03:41AM proBNP-790 [2188-4-16] 04:32AM proBNP-216 . MICRO: [4-12] - blood cx negative [4-12] - sputum cx >25 PMNs, <10 epis, no microorgs, sparse OP flora [4-12] - urine cx negative [4-14] - urine cx negative [4-15] - blood cx negative [4-15] - urine cx negative [4-15] - sputum cx >25 PMNs and <10 epithelial cells/100X field. 3+ GPC in pairs and clusters. Resp cx + OP flora. [4-18] - blood cx negative [4-18] - urine cx negative [4-26] - RPR pending . IMAGING: [4-11] CXR - Near-complete opacification of the right hemithorax consistent with completed pneumonectomy or collapse of postoperative right lung, unchanged from studies dating back [2182]. Persistent left lower lobe peribronchial infiltrate consistent with atelectasis with fibrosis or possibly pneumonia. . [4-11] CXR - There has been interval placement of an endotracheal tube approximately 5 cm above the carina. Nasogastric tube is also seen with tip overlying the stomach. Otherwise, no significant change is seen from prior study. . [4-11] EKG - Sinus tachycardia, rate 138. Since the previous tracing of [2184-12-22] the heart rate is faster. Some technical artifacts are present. There has been an axis shift to the left. An RSR' pattern is present in lead V1. The QRS complex is somewhat widened. No other changes are seen. Intervals Axes Rate PR QRS QT/QTc P QRS T 138 128 116 316/396.85 6 -134 15 . [4-13] CXR - Tip of the ETT is in similar position and the NGT appears to be in the antrum of the stomach. Slight patchiness at the left lower lung is subtly more dense compared to the prior study, the remainder of the left lung is clear and unchanged. No change in pulmonary vascular status. Features of right pneumonectomy are also unchanged . [4-13] CXR - The ETT and NGT have been removed. Right pneumonectomy space is unchanged. There continues to be some patchiness in the left lower lung but not significantly different. No change in pulmonary vascular status. . [4-14] CXR - There has been surgery in the right hemithorax with rib removal. This may have been the pneumonectomy or lobectomy with collapse of the remaining right lung present since [2184]. Aeration at the left lung base since that time has been poor probably due to chronic scarring and atelectasis perhaps with some bronchiectasis. The appearance on the films during this hospitalization has been stable and not appreciably different compared to [2184]. Rightward mediastinal shift is unchanged. The heart is not significantly enlarged. ET tube is in standard placement. Tip of the nasogastric tube is at the pylorus. No pneumothorax. . [4-14] CXR - The patient is status post right pneumonectomy with chronic interstitial markings and scarring involving the left lung base. There is unchanged rightward shift of the trachea and mediastinal structures. An endotracheal tube is unchanged in a standard position. Although, assessment of the right internal jugular venous catheter is slightly limited secondary to mediastinal shift, the tip likely terminates in the distal SVC. No pneumothorax is identified. A nasogastric tube is seen with its tip in the antrum of the stomach. . [4-14] ECHO - Suboptimal image quality. The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and systolic function appear normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no aortic valve stenosis. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [2184-10-27], the overall LVEF has improved. . [4-15] CXR - The complete opacification of the right hemithorax with right mediastinal shifting is unchanged representing most probably previous pneumonectomy. ET tube is in unchanged standard position. The NG tube and right internal jugular venous line are in standard position unchanged. There is a prominent interstitial marking involving the right lung with perihilar and lower zone redistribution suggesting congestive heart failure. The left lung base is out of the film view, the small amount of left pleural effusion cannot be excluded. . [4-18] CXR - Poor aeration at the left lung base has been a chronic feature since [2183], somewhat more pronounced throughout this hospitalization since [4-11], suggesting that the findings are chronic rather than acute. Pulmonary vascular congestion is present but there is no appreciable edema. Right lung has been consistently airless since [2183], presumably fully resected following previous lobectomy. Rightward mediastinal shift is stable. A nasogastric tube ends in the distal stomach, ET tube in standard placement, and tip of the right jugular line projects over the SVC. No pneumothorax. . [4-18] EKG - Initially a sinus beat followed by an atrial premature complex with initiation of a regular tachycardia of mechanism uncertain - possoibly AV nodal reentry. Right bundle branch block. Left anterior fascicular block. Since previous tracing of same date, tachyarrhythmia present Intervals Axes Rate PR QRS QT/QTc P QRS T 157 0 130 312/400.28 0 -68 57 . [4-19] CXR - Patient is status post right pneumonectomy. There is shift of the mediastinum to the right, unchanged since the prior chest x-ray. There has been no significant change since the prior chest x-ray of [4-18]. Chronic changes only are identified. . [4-21] CXR - Improving aeration within the left lung base. Otherwise, no significant interval change in appearance of the chest since the prior study. . [4-23] CXR - Portable semi-erect AP radiograph of the chest was reviewed, and compared to previous study of [2188-4-21]. The patient has been extubated. The nasogastric tube has been removed. The patient has prior right pneumonectomy. The previously identified left lower lobe aspiration pneumonia has been improving. There is emphysema in the remaining left lung. The heart size is not evaluated. There is continued marked tortuosity of the thoracic aorta. There is a right jugular IV catheter terminating in the superior vena cava. . [4-24] VIDEO SPEECH/SWALLOW - Mild oral dysphagia with functional pharyngeal swallow. No evidence of aspiration. . [4-27] MRI - There is no evidence of hemorrhage, edema, masses, mass effect or infarction. The ventricles and sulci are dilated compatible with the patient's age. There are no diffusion abnormalities. There is no abnormal enhancement after contrast administration. There is partial opacification of the mastoid air cells bilaterally. This may reflect acute or chronic inflammation. CONCLUSION: Mastoid opacification. The study is otherwise normal for age. Brief Hospital Course: 78yo M with MMP who presents with hypoxic respiratory failure s/p intubation x2, called out to floor for further management. . # ICU COURSE: Mr. [Known lastname 4223] was found to be in respiratory distress at home. His family was concerned for either an aspiration event or flash pulmonary edema (as he has a history of this in the past), treated him with lasix, and called EMS. On transfer to the ER, he was hypoxic and hypotensive. He was intubated in the ED, BP was stabilized with IVF and was transferred to MICU. He was initially felt to be in respiratory distress secondary to CHF, so he underwent diuresis and was extubated the following day. However, he continued to be tachycardic and tachypneic following extubation and had to be reintubated on [4-14]. A BNP was checked at that time and was 790, leading the team to think that CHF was less likely, but that COPD and pneumonia were more likely contributing as the patient was febrile and had an infiltrate on CXR, as well as wheezing on exam. TTE also demonstrated an EF of >50% making CHF less likely (though diastolic failure was still a possibility given his tachycardia). He was treated with antibiotics (Levo/Vanc) and eventually extubated successfully on [4-22]. He was monitored on an insulin gtt while in the MICU and was switched over to a RISS on [4-23]. He was given TF while in the MICU, but when he was extubated, his OGT was pulled out. He changed his code status to DNR/DNI after being extubated and also told his family he did not want a feeding tube. . Of note, while being monitored on telemetry in the MICU, it was noted that Mr. [Known lastname 4223] had intermittent bursts of SVT, with a HR as high as 160s for short periods of time. He had an unknown allergy to b-[Last Name (LF) 7005], [First Name3 (LF) ] the team was originally concerned about how to best achieve rate control. Since the episodes were transient, they did not treat immediately w/ rate control. Cards/EP were consulted and felt that the bursts were SVT, either atrial tachycardia or AVNRT. Recommendations were made for rate control w/ bblocker if patient could tolerate it, CCB or sotalol. B-blockade was started after the patient had 10 minutes of SVT on [4-18]. When he has these episodes of tachycardia, he becomes hypotensive (SBP in the 60s) but is asymptomatic. . Floor Course: # CV: 1) RHYTHM: As noted above, Mr. [Known lastname 4223] was found to have an SVT while being monitored on telemetry in the MICU. Cardiology/EP both saw the patient and recommended beta-blockade. He did not have a repeat episode of prolonged tachycardia after [4-18] when beta-blockade was started, but did continue to have short bursts of SVT daily, sometimes with activity, but often with rest. Although cardiology and EP were consulted, it was unclear what the etiology of his SVT was. He has a history of autonomic neuropathy which may explain his recurrent SVTs. However with the concomitant use of albuterol for his presumed COPD flare, his SVT may have been partially iatrogenic in nature. Albuterol was switched to xopenex to decrease adrenergic stimulation/induced tachycardia. Other possible adrenergic stimulants included PNA, hypoxia, hyperthyroidism or PE. He was continued on telemetry with good rate control (80s-90s) and his beta-[Month/Year (2) 7005] dose was stable at 37.5 TID for several days prior to discharge. . 2) PUMP: Mr. [Known lastname 4223] was initially felt to be in CHF. His BNP was only 790, though, and his TTE demonstrated an improved EF with mild LA enlargement. It was felt that he likely had diastolic failure, perhaps from his tachycardia/SVT. On transfer from the MICU, he appeared euvolemic and we allowed him to autoregular his fluid status. He was LOS negative 4.5L on transfer. He was continued on metoprolol, but no ACE was started given his reported allergy to ACE-i in the past. It is recommended that after his acute illness resolves that he talk to his PCP about the possible benefits of retrying an ACE-i or using [First Name8 (NamePattern2) ] [Last Name (un) ]. . 3) COR: He has known CAD from cath in [2183] and is s/p RCA stent x2 for discrete lesions. However, Mr. [Known lastname 4223] has been without any significant troponin leak to suggest ischemia as source of his respiratory distress. He was continued on a daily asipirin and beta-blockade, but a statin was not started given his history of an allergy to pravachol. . 4) VALVES: Mr. [Known lastname 4223] had no obvious murmurs on exam and no findings on TTE to suggest valvular disease. .. # DM: Mr. [Known lastname 4223] has long standing DM, though his HgbA1C during his hospitalization was 6.4. It was felt that his autonomic neuropathy may be due to his DM. For glycemic control, he had been on an insulin gtt in MICU, but he was transitioned to a [Hospital1 ] NPH insulin regimen on the floor, along with a RISS, with good control of his fingersticks. He was discharged on a lower dose of insulin than he was taking at home as his FS were well controlled on this, however this may need to be titrated back up if his PO intake or FS increase in the future. .. # AUTONOMIC NEUROPATHY: His autonomic neuropathy was most likely a consequence of his long standing DM, and it was also felt that this may be the source of his SVTs. He was on desmopressin, midodrine and florinef at home. Neurology was consulted and recommended discontinuing DDAVP, midodrine and florinef given that he was having more tachycardia and HTN. However, once discontinuing these medications, he began to have orthostatic hypotension when working with PT and getting OOB to a chair. Midodrine was restarted at 5mg PO TID. Per neurology, an MRI was ordered to evaluate for watershed stroke. MRI showed no evidence of stroke or encephalopathy. Reglan was also discontinued as it could be making his symptoms worse. Orthostatics were rechecked one day prior to discharge on Midodrine and were negative. .. # COPD: On transfer from the MICU, he was being treated for a COPD flare. He was receiving albuterol nebulizers, but the primary team decided to discontinue albuterol as it could be worsening his tachycardia and instead changed his regimen to xopenex and ipratroprium nebulizers. He was also continued on advair. His spiriva was held while he was receiving ipratroprium nebulizers around the clock. He did well from a respiratory standpoint and was maintaining sats of 100% on 4L. His oxygen was weaned down to 3L (his baseline is 2-3L at home). He was transitioned to prn nebulizers and spiriva was restarted. He was treated for presumed pneumonia with levofloxacin ([4-12] - [4-18]) and vancomycin ([4-18] - [4-25]). .. # CHRONIC PANCREATITIS: Pain control was with fenatanyl patch 100 Q72 (as his home regimen) and morphine IV PRN for breatkthrough pain. Creon was restarted once he passed the speech and swallow exam. Morphine was changed to percocet prn prior to discharge, to replicate his home regimen. .. # PSYCH: He was continued on his outpatient doxepin dose. .. # MGUS: It was felt that his MGUS was not an active issue currently. We continued to monitor his calcium daily and it remained within normal range throughout his hospitalization. . # FEN: Mr. [Known lastname 4223] originally failed the first speech and swallow exam at the bedside. On [4-24], he underwent a video speech and swallow exam and passed that exam, with only mild oral dysphagia and no aspirations. His diet was advanced to ground solids, thin liquids, and aspiration precautions. He required no further IVF on the flor. His electrolytes were checked daily and were repleted prn. . # PPx: Mr. [Known lastname 4223] was given SQ heparin for DVT ppx, PPI for GI ppx and bowel regimen. . # COMM: With daughter [Name (NI) ] ([Name2 (NI) ] nurse) and his wife. . # CODE: DNR/DNI/No feeding tube. Confirmed with ICU team and pt's family on [2188-4-23]. . Medications on Admission: MVT ASA 325 Vitamin D 50K units q monday DDAVP 0.1 mg/ml spray daily Creon caplets 2 tablets tid Reglan Protonix Florinef (daughter gives if bp <130) Lasix 40 mg daily (daughter gives if bp>170) Klor-con 20 meq [Hospital1 ] Magnesium oxide 400 mg [Hospital1 ] Duragesic patch 100 mcg/hr Advair Doxepin spiriva Percocet prn Insulin: regular 4 units qam, 6 units qpm; nph 20 units qam, 10 units qpm B12 shots every 2 months Discharge Medications: 1. Doxepin 25 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 2. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 3. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 6. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 8. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: One (1) nebulizer Inhalation q6hrs () as needed for SOB/wheezing. 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 13. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Insulin Regular Human 100 unit/mL Solution Sig: Varied units Injection ASDIR (AS DIRECTED): As per sliding scale. 16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Varied units Subcutaneous twice a day: 5u QAM, 2u QPM. 17. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a day. 18. Vitamin B12-Vitamin B1 100-1 mg/mL Solution Sig: Dose unknown units Intramuscular q 2 months. 19. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) inhaler Inhalation twice a day. 20. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Primary diagnosis: # Respiratory failure # Pneumonia . Secondary diagnosis: # CHF w/EF 20% in [2183] (prior to cath) - dtr reports worsening LVH # CAD s/p RCA stent [2183] # Lung ca s/p R pneumonectomy [2180], s/p chemo, no XRT # chronic pancreatitis # Type 2 DM on insulin, w/severe neuropathy (?autonomic) # gastritis # s/p ccy # HTN # MGUS # h/o flash pulmonary edema requiring intubation Discharge Condition: Good. Afebrile, VSS. Discharge Instructions: Please take all your medications as prescribed. . Please call your PCP or go to the nearest ER if you develop any of the following symptoms: fever, chills, shortness of breath, difficulty breathing, worsening cough, abdominal pain, nausea, vomiting, diarrhea, difficulty eating or swallowing, or any other worrisome symptoms. . Please keep all your follow-up appointments. Followup Instructions: You have a follow-up appointment scheduled with Dr. [Last Name (STitle) 11679] on Thursday, [5-8] at 2:00. Please call his office at [Telephone/Fax (1) 2394] with any questions. Completed by:[2188-4-30]	[ "428.0", "507.0", "250.60", "428.30", "V45.82", "414.00", "357.2", "584.9", "491.21", "V58.67", "V10.11", "518.81", "427.89", "577.1" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.04", "96.72", "96.6", "96.71" ]	icd9pcs	[ [ [] ] ]	21551, 21622	11103, 19088	366, 390	22070, 22093	3501, 3506	22514, 22736	2967, 2976		19569, 21528		21643, 21643		19114, 19546				22117, 22491													2991, 3482																										307, 328							418, 2340				21719, 22049			21662, 21698		3520, 11080								2362, 2726	2742, 2951
47,563	139,080	36257	Discharge summary	report	Admission Date: [2108-6-4] Discharge Date: [2108-6-7] Date of Birth: [2086-5-3] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[First Name3 (LF) 9415] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: Mr [Known lastname ] is a 22M w SCZ x1 year, stable on clozapine, who now p/w AMS. . Per MICU admission note, pt was in his USOH until the day of admission, when at 4am he experienced insomnia [2-27] racing thoughts. He called his mother and told her that he has not taken his meds since moving to [Location (un) 86] 2-3 days ago. She told him to take his usual nighttime meds-- clozapine 200mg and sertraline. He called her back at 4:30am and informed her that he took 7 clozapine 100mg tabs in an attempt to "stop the racing thoughts". His mother called poison control who recommended calling EMS. . Per mother, pt took overdose of clonopin (9 tabs) about one year ago for similar reason. Also has history of [4-29] psych hospitalizations, at least one for suicidal ideation. . In the ED, was persistently tachy to 120-140s. BP remained stable. Satting well on RA. Was agitated, mumbling, slurring speech. EKG with slightly prolonged QTc, concern for TCA toxicity, however no change with amp of bicarb x 2. Serum and urine tox negative. Admitted to MICU for close monitoring. . Toxicology consult thought findings were consistent with clozapine OD, recommended serial EKGs, supportive care and benzos for agitation. Pt had a reported episode of priapism, which resolved without intervention. Pt remained tachycardic in the 112-139 range x 24 hours, mental status improved. . On transfer to the medicine floor, pt reports continued "racing thoughts" and feeling tired. Denies F/C, CP/SOB, abd pain, N/V/D or urinary sxs. Denies hearing voices or suicidal ideation. Past Medical History: -Schizophrenia- hospitalized 4-5 times, was being followed by Dr. [Last Name (STitle) 82193] ([Location (un) 82194], ME [Telephone/Fax (1) 82195]), CSI counseling service ([Telephone/Fax (1) 82196]) -Anxiety Social History: Recently moved from [State 1727] to [Location (un) 86] to start college. Smoking: occasional (last cigarette 1 month ago) EtOH: social (3-5 drinks/day 2-3x per week) Drugs: h/o marijuana in the past Family History: Grandmother with anxiety. Maternal uncles with depression. Paternal grandmother also with psychiatric problems Physical Exam: Vitals: T: 96.1, BP: 131/69, P: 137, R: 14, O2: 99% on RA General: alternating between somnolence and agitation with any provocation, non-verbal, mumbling occasionally, moving all extremities HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: LABS: [2108-6-4] 05:50AM BLOOD WBC-9.3 RBC-4.89 Hgb-14.3 Hct-41.1 MCV-84 MCH-29.3 MCHC-34.8 RDW-13.7 Plt Ct-271 [2108-6-4] 05:50AM BLOOD Neuts-54.2 Lymphs-35.3 Monos-6.2 Eos-3.7 Baso-0.5 [2108-6-4] 05:50AM BLOOD Glucose-149* UreaN-15 Creat-1.0 Na-136 K-5.0 Cl-101 HCO3-26 AnGap-14 [2108-6-5] 05:32AM BLOOD ALT-22 AST-22 CK(CPK)-179* AlkPhos-121* TotBili-0.3 [2108-6-5] 05:32AM BLOOD TSH-1.9 . TOX: [2108-6-4] 05:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2108-6-4] 06:25AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . URINE: [2108-6-4] 06:25AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.023 [2108-6-4] 06:25AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR [2108-6-4] 06:25AM URINE RBC-0.2 WBC-[3-29] Bacteri-FEW Yeast-NONE Epi-0 . CARDIOLOGY: [6-4] - EKG: Sinus tachycardia. Normal tracing except for the rate. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 105 140 110 348/426 64 68 46 . [6-6] - EKG: Normal sinus rhythm. No ST/TW changes. QTc wnl. . RADIOLOGY: CXR ([6-4]): IMPRESSION: Within normal limits. Brief Hospital Course: In short, Mr [Known lastname ] is a 22M w SCZ on clozapine, who p/w AMS [2-27] clozapine overdose. . # CLOZAPINE OVERDOSE: Clinical picture was consistent with atypical antipsychotic medication toxidrome: anti-alpha1-adrenergic effects (sinus tachycardia 110s-130s), anti-histaminic effects (sedation), anti-cholinergic effects (confusion, flushing, dry mouth). Also mild prolongation in QTc on admission. No electrolyte abnormalities. Tox screens negative. Pt received supportive care and was monitored in the CCU in the first 24 hrs. He was seen by toxicology and psychiatry. Pt denies suicidal ideation, acknowledges that he should not have taken more than the prescribed number of clozapine pills. He is discharged with his mother present on his prior home regimen with outpatient followup with his psychiatrist in [State 1727]. Follow-up appointments in [State 350] pending insurance paperwork (BEST referral for psychiatry, [Company 191] appointment for primary care). Contracted for safety. . # ERECTION: Reported to have a 2-3 hour episode of erection in the ED, which could have been [2-27] clozapine (case reports of associated priapism). Urology consulted, recommended conservative measures. Erection resolved. . # SCHIZOPHRENIA: Pt currently denies positive sxs. Seen by psychiatry. Restarted on clozapine 100qam, 200qpm. Needs outpatient followup. . # CONTACT: mother [Name (NI) ] [Name (NI) ] [Telephone/Fax (1) 82197] (home) in [State 1727] Medications on Admission: Clozaril 100mg qAM, 200mg qPM Zoloft (unclear dose) Discharge Medications: 1. Clozapine 100 mg Tablet Sig: Two (2) Tablet PO at bedtime. 2. Zoloft 100 mg Tablet Sig: One (1) Tablet PO once a day. 3. Clozapine 100 mg Tablet Sig: One (1) Tablet PO qam. Discharge Disposition: Home Discharge Diagnosis: clozapine overdose . schizophrenia anxiety Discharge Condition: improved, alert, oriented x3, hemodynamically stable Discharge Instructions: You were admitted to the hospital for taking too much of your clozapine. We monitored you for possible toxic side-effects and provided supportive care. Your condition has now improved. . Please take your medications as directed in the future. 1. clozapine 100mg in the morning, 200mg in the evening 2. sertraline 100mg in the morning . If you have any fevers, chills, shortness of breath, chest pain, palpitations, confusion, dizziness, lightheadedness, abdominal pain, or any other concerning symptoms, please call your physician [Name Initial (PRE) 2227]. Followup Instructions: Please call [Hospital3 ] at [Hospital1 18] for primary care appointment within a week of your discharge: [Telephone/Fax (1) 250]. . You were given extensive information regarding BEST referral for psychiatry followup in [Location (un) 86]. Until an appointment can be made, please follow up with your psychiatrist in [State 1727]: Dr. [Last Name (STitle) 82193] ([Location (un) 82194], ME [Telephone/Fax (1) 82195]). Completed by:[2108-6-7]	[ "305.1", "300.00", "780.97", "427.89", "295.90", "E950.3", "969.3" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	6246, 6252	4444, 5943	315, 322	6339, 6394	3169, 4421	7004, 7483	2421, 2533		6045, 6223		6273, 6318		5969, 6022				6418, 6981													2548, 3150																										254, 277							350, 1933																	1955, 2180	2196, 2405
44,190	114,812	36996	Discharge summary	report	Admission Date: [2126-6-29] Discharge Date: [2126-7-23] Date of Birth: [2077-7-17] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 974] Chief Complaint: Multiple stab wounds to chest, abdomen, neck, and head Major Surgical or Invasive Procedure: 1. Trauma laparotomy with repair of stab wound enterotomies x36 and total mobilization left colon. 2. Bilateral neck exploration 3. Laparotomy and lysis of adhesions, reduction of internal hernias and volvulized small bowel segment. History of Present Illness: 48 yo male patient with MS, [First Name3 (LF) ], and substance abuse presents with multiple stab wounds to chest/abdomen/neck/head with an ice pick. He presented with tension PTX. 2 chest tubes were placed and he was taken to OR for multiple stab wounds. Past Medical History: MS [First Name (Titles) ] [Last Name (Titles) 7344] abuse Social History: -[Name (NI) ], wife of 23 years, left him in [3-14] -sister [Name (NI) 5627] [Name (NI) 83433] ([Telephone/Fax (1) 83434]) is his health care proxy -patient living in his mother's house in [Location (un) 5503] Family History: Not applicable to current care Physical Exam: Upon admission: T:100.6 BP:165/78 HR:97 RR:30 O2Sats:95% on shovel mask at 95% Gen: Patient is agitated and leans to the right side in the bed. HEENT: Right orbit is swollen shut, ecchymotic, and erythematous Pupils:were dilated by opthamology today - 8mm bilaterally EOMs-impaired in the right eye, intact in the left eye Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, +tenderness, there are multiple stab wounds, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, somewhat uncooperative with exam, flat affect. Orientation: Oriented to person and hospital. Language: Slight dysarthria, perseverative. Does not appear able to comprehend complex commands. Cranial Nerves: I: Not tested II: Pupils have both been dilated by opthamology and are 8mm bilaterally. III, IV, VI: Extraocular movements intact on the left and impaired on the right. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [4-9] on the right side. The LUE 5-/5 and the LLE is [4-9] in IP and [3-10] distally. Unable to participate with pronator drift testing. Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally Pertinent Results: [2126-6-29] 11:15PM TYPE-ART TEMP-36.9 RATES-18/ TIDAL VOL-450 PEEP-0 O2-60 PO2-138* PCO2-48* PH-7.25* TOTAL CO2-22 BASE XS--6 INTUBATED-INTUBATED VENT-CONTROLLED [2126-6-29] 11:03PM GLUCOSE-142* UREA N-14 CREAT-0.9 SODIUM-149* POTASSIUM-4.0 CHLORIDE-120* TOTAL CO2-22 ANION GAP-11 [2126-6-29] 11:03PM WBC-13.6* RBC-3.19* HGB-10.6* HCT-33.4* MCV-105* MCH-33.4* MCHC-31.8 RDW-14.4 [2126-6-29] 11:03PM PLT COUNT-343 [2126-6-29] 11:03PM PT-13.0 PTT-26.5 INR(PT)-1.1 [2126-6-29] 01:39PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2126-6-29] 01:39PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG Brief Hospital Course: Mr [Known lastname 45957] is a 48 year old male w/ PMH of multiple sclerosis who was admitted to the Trauma service; in the ED he was noted with tension pneumothorax upon arrival and received a chest tube. He was taken to the operating room for trauma laparotomy secondary to multiple stab wounds; 35 enterotomies were found in his small intestine and were oversewn. He was rewarmed in the unit and taken back to the OR for exploration of 3 stab wounds to his neck. Head CT showed intraventricular hemorrhage and a neurosurgical consult was obtained. It was felt that this bleed did not require surgical management. Serial head CT scans were followed and the initial follow up scan did reveal an increase in the intraventricular hemorrhage. His neurologic status was watched closely, a repeat head CT on the next day remained stable with no interval increase. Presently his mental status is that he is alert, oriented x2-3, with some short term memory loss; and he is cooperative with his care. He will follow up as an outpatient with Dr. [Last Name (STitle) 548] for repeat head imaging. During his hospitalization, Mr. [Known lastname 45957] was seen by Psychiatry and his meds were adjusted to decrease agitation and avoid sedation. He was seen by Ophthalmology, Plastics, and Neurology for damage to his right eye which prevents him from opening the lid, although he has preserved vision. An MR of his head and orbits were done which did show a right inferior rectus muscle into the fracture defect. Plastics felt that this was caused by superior orbital fissure syndrome and recommended that he see Dr. [First Name8 (NamePattern2) 2398] [Last Name (NamePattern1) ] at [Hospital3 2576] for evaluation and treatment in the next several weeks. No procedures were done in the hospital for his eye; he was prescribed eye drops. While in the hospital, he was treated with vancomycin/Cipro/Zosyn for fever and altered mental status. He had a fever work-up which revealed pan-sensitive E. coli in his urine. He completed a course of Cipro and antibiotics were discontinued. On HD # 18 he acutely developed nausea and vomiting requiring an NGT placement. A CT scan of his abdomen confirmed a post-operative mechanical obstruction. He was taken back to the operating [2126-7-16] for laparotomy and lysis of adhesions. He was admitted back to the floor and made NPO with NGT and maintained on IVF. On POD 1 the NGT was removed and his diet was slowly advanced as tolerated. He is currently tolerating a regular diet. He was followed by Social work due to the nature of his trauma. He was also evaluated by Physical and Occupational therapy and is being recommended for short term rehab following his acute hospital stay. Medications on Admission: Confirmed from pharmacy: Paroxetine 40mg qhs (from Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]); trazadone 100mg qhs, topiramate 100mg [Hospital1 ] (filled [6-12]), seroquel 50mg TID prn agitation (filled [6-26])-these 3from Dr. [Last Name (STitle) 83435]; excelon 6mg [Hospital1 ],baclofen, naproxen Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for heartburn. 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. Tetracaine HCl 0.5 % Drops Sig: Three (3) drops Ophthalmic once a day: OU. 5. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for PRN agitation. 6. Topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Rebif 44 mcg/0.5 mL Syringe Sig: One (1) Subcutaneous 3 times per week . 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: hold for loose stools. 9. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation. 10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 11. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5,000 Units Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 672] Hospital Discharge Diagnosis: s/p Multiple stab wounds to abdomen, chest, face, and neck Left maxilla fracture Bilateral orbital roof fractures w/ right inferior rectus entrapment Samll intraventricular hemorrhage Pneumomediastinum Small bowel obstruction Discharge Condition: Hemodynamically stable; pain adequately controlled and tolerating a regular diet Discharge Instructions: Followup Instructions: Please follow up with Dr. [Last Name (STitle) 548], Neurosurgery in 3 weeks with head CT. Please call [Telephone/Fax (1) 2992] for this appt. Please call Dr. [First Name8 (NamePattern2) 2398] [Last Name (NamePattern1) ] at [Hospital3 ] to schedule an appointment for ongoing evaluation and treatment of your eye. The number is:([Telephone/Fax (1) 83436] Please follow-up with Dr. [Last Name (STitle) ] in trauma clinic in 2 weeks for evalaution following your small bowel surgery. The number to call and schedule an appointment is [Telephone/Fax (1) 2359]. Please follow up with your primary care Neurologist Dr. [Last Name (STitle) 77121] after discharge from rehab for continued management of your multiple sclerosis. Completed by:[2126-7-23]	[ "340", "378.9", "305.1", "276.2", "863.30", "802.4", "860.1", "870.8", "801.21", "303.90", "305.60", "560.81", "292.0", "560.1", "041.4", "291.81", "599.0", "997.4", "958.7", "E966", "507.0", "348.5", "285.9", "296.44", "276.0" ]	icd9cm	[ [ [] ] ]	[ "53.49", "96.6", "54.59", "34.04", "96.71", "53.9", "06.09", "46.73" ]	icd9pcs	[ [ [] ] ]	7715, 7770	3509, 6264	368, 603	8040, 8123	2786, 3486	8171, 8963	1249, 1281		6661, 7692		7791, 8019		6290, 6638				8148, 8148													1296, 1298																										274, 330							631, 893	2023, 2767								1312, 1784		1799, 2007						915, 982	998, 1233
26,921	117,828	23756	Discharge summary	report	Admission Date: [2113-7-21] Discharge Date: [2113-8-15] Date of Birth: [2044-9-24] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) / Prednisone / Avelox Attending:[First Name3 (LF) 1283] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [7-21] Cardiac Catherization [7-25] Coronary artery bypass graft x 2 (Left internal mammary artery > Left anterior descending, Saphenous vein graft > Posterior descending artery) Aortic Valve replacement (25mm Mosaic porcine) Mitral Valve Repair (28mm annuloplasty band), Ascending Aorta Replacement (26mm gelweave) [8-1] Sternal Debridement [8-2] pectoral & omental flap closure Cardioversion History of Present Illness: 68 yo male with extensive PMH and increasing DOE with fatigue. Serial echos have shown decreasing [Location (un) 109] with current 1.0 cm2. PFTS in [4-24] showed moderate obstructive and mild restrictive lung disease. Chest CT in [6-24] showed asc. aorta 4.7 cm and 3.7 cm at the aortic root. Cath in early [Month (only) 216] revealed RCA 100%, 40% LAD, 40% pCX, and occluded distal CX. Referred for surgery. Past Medical History: Coronary artery disease Aortic Stenosis Mitral Regurgitation Atrial Fibrillation Obesity Hypertension Elevated cholesterol PAF and previous cardioversions and ablation Chronic obstructive pulmonary disease PVD/carotid dz. catheter ablation MVA with 2 prior lumbar surgs. prior bil. carpal tunnel surgs. prior sinus [Doctor First Name ]. left ankle surgs. x2 tonsillectomy facial [Doctor First Name ]. (MVA) quad. tendon rpair hernia repair Social History: never used tobacco retired photographer rare use of ETOH lives with wife Family History: father expired of MI @54; mother died of CAD @67 Physical Exam: Admission Vitals 75, 132/74, 20, 98 O2 Sat JVP no distention, Carotids no bruit Lungs CTA bilaterally Abd Soft, NT, ND Pulses +2 radial, femoral, DP, PT bilat Pertinent Results: [2113-7-21] 02:05PM HGB-11.6* calcHCT-35 O2 SAT-97 [2113-8-14] 06:09AM BLOOD WBC-12.4* RBC-3.53* Hgb-10.6* Hct-31.9* MCV-90 MCH-30.1 MCHC-33.3 RDW-14.9 Plt Ct-631* [2113-8-12] 04:51AM BLOOD WBC-11.6* RBC-3.24* Hgb-10.1* Hct-29.3* MCV-91 MCH-31.1 MCHC-34.3 RDW-15.0 Plt Ct-526* [2113-8-10] 06:00AM BLOOD WBC-12.3* RBC-3.31* Hgb-10.4* Hct-30.9* MCV-93 MCH-31.3 MCHC-33.6 RDW-15.5 Plt Ct-605* [2113-8-14] 06:09AM BLOOD Plt Ct-631* [2113-8-14] 06:09AM BLOOD PT-16.7* PTT-27.2 INR(PT)-1.5* [2113-8-13] 05:35AM BLOOD PT-19.1* INR(PT)-1.8* [2113-8-14] 06:09AM BLOOD Glucose-100 UreaN-33* Creat-1.3* Na-132* K-4.8 Cl-92* HCO3-33* AnGap-12 [2113-8-13] 05:35AM BLOOD UreaN-33* Creat-1.2 K-4.5 [2113-8-12] 04:51AM BLOOD Glucose-96 UreaN-34* Creat-1.2 Na-130* K-4.4 Cl-92* HCO3-31 AnGap-11 [2113-8-10] 06:00AM BLOOD Glucose-109* UreaN-35* Creat-1.4* Na-128* K-4.5 Cl-91* HCO3-28 AnGap-14 [2113-8-9] 03:02AM BLOOD ALT-85* AST-83* AlkPhos-125* Amylase-33 TotBili-4.6* [2113-8-7] 10:02AM BLOOD ALT-62* AST-50* LD(LDH)-324* AlkPhos-76 Amylase-33 TotBili-5.7* Brief Hospital Course: Admitted [7-21] for heparin coverage while off coumadin and cardiac catherization. The catherization revealed RCA 100%, 40% LAD, 40% pCX,and occluded distal CX. Carotid US did not show any significant stenosis. He went to the operating [**] for coronary artery bypass graft, aortic valve replacement, mitral valve repair, and ascending aorta replacement. Please see operative for further details. He was transferred to the CSRU in stable condition on phenylephrine and propofol drips. In the first twenty four hours he awoke neurologically intact, weaned from sedation and was extubated without complications. He received a five day course of azithromycin given by history for chronic sinusitis each time the he has been intubated in the past. Cardiology was consulted due to ST elevations in V2-V6 with pericardial rub, Echo and EKG obtained. Started on NSAID for pericarditis and plavix for poor targets. Transferred to the floor on POD #2 to begin increasing his activity level. He was gently diuresed toward his preoperative weight and beta blockade titrated. Pacing wires removed without incident on POD #3. He went into Atrial fibrillation [7-29], but converted back to sinus rhythm. He again went into rapid atrial fibrillation and was treated with amiodarone and lopressor with no response. He was then bolused and started on cardiazem drip that he converted to sinus rhythm for a few hours and then went into atrial flutter. Electrophysiology was consulted and plan for cardioversion. He developed a sternal click and chest xray revealed sternal dehiscence on POD 6. He returned to the OR POD 7 for sternal debridement and cardioversion. He then went to the OR on POD 8 with Dr. [First Name (STitle) ] (plastics) for debridement and omental flap closure. Transferred to the CSRU and then extubated again on [8-3]. EP re-consulted for continuing A fib management. Diagnosed with a probable TIA on [8-5]. Started on coumadin on [8-6]. Transferred back to the floor on [8-9]. Continued to make good progress and was cleared for discharge to rehab on [8-15]. Pt. is to make all follow-up appts. as per discharge instructions. Medications on Admission: toprol XL 25 mg daily verapamil 120 mg daily lisinopril 5 mg daily coumadin 5 mg daily (last dose 7/27) ASA 81 mg daily zetia 10 mg daily singulair 10 mg daily mucinex 600 mg 2-4 tabs daily aldactazide 25/25 mg 2 tabs daily advair 250/50 one puff [Hospital1 ] nasocort AQ mcg 2 sprays daily NTG 0.4 mg one spray daily albuterol 17 gm 2 puffs QID prn azmacort 20 gms 2 puffs [Hospital1 ] prn Tussi-Organi 2 tsp q 4 hours prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. 4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day): one inhalation [Hospital1 ]. 8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours). 12. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). 13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days: then 200 mg daily until seen by Dr. [Last Name (STitle) ]. 15. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Coronary artery disease s/p CABG Aortic Stenosis s/p AVR Mitral Regurgitation s/p MV Repair Atrial Fibrillation Atrial Flutter s/p Cardioversion sternal dehiscence/debridement/flap closure Obesity Hypertension Elevated cholesterol PAF and previous cardioversions and ablation Chronic obstructive pulmonary disease PVD/carotid dz. catheter ablation MVA with 2 prior lumbar surgs. prior bil. carpal tunnel surgs. prior sinus [Doctor First Name ]. left ankle surgs. x2 tonsillectomy facial [Doctor First Name ]. (MVA) quad. tendon rpair hernia repair Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Please call to schedule all appointments Dr. [First Name (STitle) ] (Plastic Surgery) in 1 week ([Telephone/Fax (1) 1429] Dr. [Last Name (STitle) 1290] in 4 weeks [Telephone/Fax (1) 170] Dr. [Last Name (STitle) 2161] or Dr. [Last Name (STitle) 60676] (PCP) in [12-20] weeks [Telephone/Fax (1) 60677] Dr. [Last Name (STitle) 60678] (Cardiologist) in [1-21] weeks Dr [Last Name (STitle) 60679] (electrophysiology) in [1-22] weeks [Telephone/Fax (1) 2934] Completed by:[2113-8-15**]	[ "414.01", "401.9", "998.32", "746.4", "441.2", "473.8", "423.8", "427.31", "435.9", "424.0", "496", "272.4", "997.1" ]	icd9cm	[ [ [] ] ]	[ "77.81", "36.11", "89.60", "78.41", "35.21", "99.04", "99.61", "88.56", "35.33", "37.23", "88.53", "39.61", "38.45", "77.61", "36.15", "86.74" ]	icd9pcs	[ [ [] ] ]	7473, 7552	3140, 5317	330, 742	8152, 8159	2019, 3117	8670, 9208	1775, 1825		5800, 7450		7573, 8131		5343, 5777				8183, 8647													1840, 2000																										270, 291							770, 1197																	1219, 1669	1685, 1759
46,889	105,246	7358	Discharge summary	report	Admission Date: [2200-10-21] Discharge Date: [2200-10-31] Date of Birth: [2137-9-11] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3984] Chief Complaint: headache, fever Major Surgical or Invasive Procedure: LP on [2200-10-21] History of Present Illness: This is a 62yo M with NSCLC stage IV s/p [Doctor Last Name ]/taxol followed by maintenance bevacizumab as part of DF-HCC 09-069, found to have brain mets and completed WBRT on [2200-9-2], now presenting with severe and progressive headache and fever. His last chemo bevacizumab was in [2200-7-14]. States he has been having headaches since 2 months, are intermittent. Now worse, waking up at night. Pt also has dizziness associated with HAs. Also endorses fever for 2 days. The pain is diffuse. It comes on gradually and lasts for several hours, then resolves entirely. Endorses bluury vision and photophobia but denies neck pain. Currently, pt is on a Dexamethasone taper per his RadOnc and NeuroOnc recommendations. In the ED, his initial VS were: 101.2 100 132/85 16 96% RA. On physical exam, CNII-[Doctor First Name 81] were intact, tongue deviates slightly to right. BUE strength and sensation intact and symmetric, BLE strength and sensation intact and symmetric. Dysmetria on finger-nose-finger, R>L. Labs notable for normal WBC, baseline Hct and Na of 127. CXR showed likely a superimposed acute interstitial process on the baseline severe emphysema, could be atypical infection such as viral or fungal etiologies though edema in the setting of emphysema may also present in this manner. CT head showed stable compared with priors, known mets remain CT occult, no acute process. LP was performed, CSF showed Protein 44, Glucose 39, WBC 33 (Poly 1, Lymph 13, Mono 8 Eos 0, Mesothe 6 and Macroph 72), RBC 3. UA was neg. Blood cultures and CSF culture were submitted. Lactate was 2.2. Pt was given 2L NS, Vancomycin, CTX and Ampicillin for possible meningitis. Pt was also given Tylenol and 2 Percocets for pain and fever. On transfer, VS were T 98.3 HR 75 O2 sat 94%on 2l nc BP 101/51. On arrival to the MICU, pt states to be "fine" except for the persistent headaches. denies n/v currently. denies neck pain. no other complaints. ROS: per HPI, otherwise neg except endorses chronic diffuse weakness and hand numbness. also endorses nausea/vomiting this am. endorses reflux symptoms. denies CP, dyspnea, abd pain. no cough, myalgias. admits to bloody stools during chemo but none since. no urinary complaints, diarrhea or constipation. Past Medical History: [Doctor First Name 27119] Emphysema (per CT) Pulmonary Fibrosis (per CT) FEV1/FVC 105% Tobacco use Motor vehicle collision requiring exploratory lap in [2158] Low back pain, herniation of L4-L5 with compression of L5 nerve root Osteopenia Lung nodule, found [2193] Hyperglycemia (HbA1C 6.4 on [2200-10-10]) Past Oncologic History: - NSCLC stage IV non-squamous EGFR wt - [4-/2199] developed bilateral supraclavicular neck swelling and tenderness which he attributed to muscular strain - [5-/2199] presented to PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] for neck swelling - [2199-5-21] thyroid/neck US: normal thyroid gland, multiple bilateral enlarged lymph nodes measuring 2.2 x 1.6 x 2.2cm at the largest. - [2199-6-3] lymph node FNA: negative for malignancy and just showed necrotic debris and macrophages. Given the very high suspicion for malignancy, possibly lymphoma, he was subsequently referred for excisional lymph node biopsy. - [2199-7-4] left cervical lymph node excision that revealed a poorly differentiated carcinoma with osteoclast-like giant cells that was strongly immunoreactive for cytokeratin AE1/AE3/CAM 5.2, cytokeratin 7 and TTF-1. It was not reactive for cytokeratin 20, S100 and MART 1. Consistent with NSCLC. - [2199-7-23] CT Torso: showed substantial lymphadenopathy present in the chest, specifically a 2.5 x 1.5 cm right upper paratracheal node, a right mediastinal 9 x 14 mm node, a prevascular node measuring 2.1 x 1.2 as well as bilateral hilar and subcarinal adenopathy. He had a 1.6 x 1.2 cm right supraclavicular node as well as a left 1.5 cm x 9 mm supraclavicular node. Within the lungs, there was irregular mass in the right upper lobe measuring 2.1 x 1.3 mm. Bilateral severe emphysema, and bibasilar ground-glass opacities in the lower lobe described as fibrosis in the peripheral distribution. Within the abdomen, the adrenals were unremarkable and in the pelvis there was no intraabdominal or pelvic lymphadenopathy. There is a T12 benign hemangioma, but no other bony disease. - [2199-8-5] bone scan: no evidence of osseous metastatic disease. - [2199-8-5] MRI brain: No intracranial metastases - [2199-8-9] CT torso for trial baseline: Unchanged from [2199-7-23]. - [2199-8-15] Signed consent for DF-HCC trial 09-069, B12 injection - [2199-8-22] started cycle 1 Paclitaxel 200mg/m2 IV, Carboplatin AUC 6, Bevacizumab 15mg/kg IV. This is Arm B in the study. - [2199-9-5] C1D15 ANC 420, grade 4 neutropenia - [2199-9-12] C2D1 Paclitaxel 150mg/m2 IV, Carboplatin AUC 4.5, Bevacizumab 15mg/kg IV (dose reduced per protocol) - [2199-10-1] CT scans with 32.7% decrease in target lesions, PR by RECIST. - [2199-10-3] C3D1 Paclitaxel 150mg/m2 IV, Carboplatin AUC 4.5, Bevacizumab 15mg/kg IV (dose reduced per protocol) - [2199-10-24] C4D1 09-069 Paclitaxel 150mg/m2 IV, Carboplatin AUC 4.5, Bevacizumab 15mg/kg IV (dose reduced per protocol) - [2199-11-11] Staging scans with 37% decrease versus baseline - [2199-11-14] C5D1 Bevacizumab (15mg/kg) maintenance - [2199-12-5] C6D1 Bevacizumab (15mg/kg) maintenance - [2199-12-23] CT Torso with ongoing PR by RECIST - [2199-12-26] C7D1 Bevacizumab (15mg/kg) maintenance - [2200-1-16] C8D1 Bevacizumab (15mg/kg) maintenance - [2200-2-4] CT Torso with ongoing PR, 40% decrease from baseline - [2200-2-6] C9D1 Bevacizumab (15mg/kg) maintenance - [2200-2-27] C10D1 Bevacizumab (15mg/kg) maintenance, taken off trial due to travel plans, will remain under long term follow up for 09-069 for survival data. - [2200-3-27] CT (prelim) with stable disease - [2200-3-27] C11D1 Bevacizumab (15mg/kg) maintenance - [2200-4-17] C12D1 Bevacizumab (15mg/kg) maintenance - [2200-5-8] C13D1 Bevacizumab (15mg/kg) maintenance - [2200-5-29] CT Torso with slight interval increase in 2 known lesions, no new sites of disease - [2200-6-5] C14D1 Bevacizumab (15mg/kg) maintenance - [2200-7-3] C15D1 Bevacizumab (15mg/kg) maintenance - [2200-7-31] HELD C16 bevacizumab for new neurologic signs - [2200-8-12] MRI showed new T1 hyperintense hyperenhancing lesions in the right basal ganglia and parietal lobes are concerning for metastatic disease. The parietal lobe lesions raised concern for leptomeningeal disease. - [2200-8-22] Started whole brain XRT with 3000 cGy - [2200-9-2] completed whole brain XRT Social History: lives with his ex-wife and daughter. Originally he is from [Country 5142]. He does smoke approximately ten cigarettes a day for the last 40 years. He does not drink alcohol now, but used to drink fairly heavily in the past. denies IVDU. Family History: mother with [Name2 (NI) ]. Physical Exam: VS- T 97.8 BP 116/68 HR 72 RR 18 O2 sat 96% on 2L weight 161 lbs height 69" Gen- well-aapearing, NAD HEENT- EOMI, PERRL, anicteric sclera, MMM, OP clear Neck- no nuchal rigidity CV- RRR, no murmurs Resp- CTAB, no wheezes or crackles Abd- soft, nontender Ext- no edema Neuro- CNII-CNXII intact, strength and sensation intact throughout Skin- no rashes Pertinent Results: Labs: [2200-10-21] 09:20AM BLOOD WBC-8.5 RBC-4.64 Hgb-14.7 Hct-42.3 MCV-91 MCH-31.6 MCHC-34.7 RDW-14.8 Plt Ct-117* [2200-10-21] 09:20AM BLOOD Neuts-83* Bands-4 Lymphs-9* Monos-2 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-1* [2200-10-21] 09:20AM BLOOD PT-12.0 PTT-24.7 INR(PT)-1.0 [2200-10-21] 09:20AM BLOOD Glucose-117* UreaN-23* Creat-0.8 Na-127* K-4.0 Cl-89* HCO3-26 AnGap-16 [2200-10-21] 09:20AM BLOOD Calcium-8.7 Phos-2.4* Mg-1.7 [2200-10-21] 09:33AM BLOOD Lactate-2.2* UA: neg Micro: Blood cultures: pnd CSF culture: pnd Imaging: CT head: IMPRESSION: Stable head CT examination demonstrating mild atrophy and chronic small vessel ischemic change. Known brain metastases remain CT occult. CXR: IMPRESSION: There is likely a superimposed acute interstitial process on the baseline severe emphysema. Diagnostic considerations favor an atypical infection such as from viral or fungal etiologies in light of the clinical history provided. Please note, edema in the setting of emphysema may also present in this manner. Correlate clinically. Brief Hospital Course: Mr. [Known lastname 24529] was a 62 year-old man with NSCLC stage IV with brain mets, completed WBRT [2200-9-2], who presented with severe headache and fever on [10-21] and transferred to the MICU on [10-22] due to worsening hypoxia and new b/l infiltrates. In the MICU, the patient was treated with cefepim+vanco+azithro to cover HAP and CAP. Also started on bactrim to cover PCP (chronic steroid use due to brain mets). The patient was ruled-out for tuberculosis. . Over Mr. [Known lastname 25039] MICU stay he became increasingly more hypoxic and required 100% FiO2 via facemask at all times. Desaturations to the high 70s with small movements even with facemask in place. Given hypoxia, fndings on imaging and an elevated BDG the working diagnosis was PCP [Name Initial (PRE) 1064]. Continued treatment with bactrim and completed course of vanc/cef/azithro for empiric coverage of HCAP. . Given the severity of the patient's infectious process and the poor prognosis of his malignancy; goals of care were adressed and the patient was made DNR/DNI. Despite treatment, his clinical status did not improve. Patient expressed the wish to remain alive until his family could arrive from [Country 5142] although did not want to be intubated. On [2200-10-31], the patient's family arrived from [Country 5142]. Over the course of that day his respiratory status continued to deteriorate and he passed away quietly and peacefully on [2200-10-31]. Medications on Admission: 1. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 2. dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO twice a day. 3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 6. clindamycin phosphate 1 % Solution Sig: One (1) application Topical at bedtime: apply to scalp nightly for rash at bedtime. 7. fluocinonide 0.05 % Solution Sig: One (1) application Topical once a day: [Doctor Last Name ] to scalp rash as needed. 8. ketoconazole 2 % Shampoo Sig: One (1) application Topical once a day: apply to scalp daily in shower. 9. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit Tablet Sig: One (1) Tablet PO twice a day: with food. 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 11. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 12. acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a day. 13. trazodone 50 mg Tablet Sig: one half Tablet PO at bedtime as needed for insomnia. Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: N/A Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] Completed by:[2200-11-1]	[ "V49.86", "733.90", "136.3", "427.5", "401.9", "492.8", "799.02", "198.3", "V58.65", "515", "162.8" ]	icd9cm	[ [ [] ] ]	[ "03.31", "38.93" ]	icd9pcs	[ [ [] ] ]	11729, 11738	8926, 10411	322, 346	11785, 11790	7840, 8394	11842, 12002	7411, 7443		11701, 11706		11759, 11764		10437, 11678				11814, 11819													7458, 7821																										267, 284							374, 2654			8403, 8903														2676, 7136	7152, 7395
13,646	179,863	17055+56824	Discharge summary	report+addendum	Admission Date: [2173-6-2] Discharge Date: [2173-6-10] Date of Birth: [2099-6-11] Sex: F Service: MICU GREEN CHIEF COMPLAINT: Respiratory failure. HISTORY OF PRESENT ILLNESS: Ms. [Known lastname 8529] is a 73-year-old female with adenocarcinoma of the lung several times status post multiple wedge resections and a right upper lobectomy on [2173-4-29]. She also has a history of significant chronic obstructive pulmonary disease. She is brought into the Emergency Department here at [Hospital3 ] by EMT after experiencing three hours of shortness of breath on the day of admission. As previously mentioned, Ms. [Known lastname 8529] [Last Name (Titles) 1834] a wedge resection of the posterior segment of her right upper lobe on [2162] for first instance of adenocarcinoma of the lung which was T1, N0, M0. She then [Year (4 digits) 1834] excision of two nodules in the left lung in [2166] followed by chemotherapy for another adenocarcinoma of the lung, and finally she had a recurrence/new incidence of adenocarcinoma in the lung in the right upper lobe which was T2, N0, M0 treated with right upper lobectomy on [2173-4-29] at [Hospital6 2910]. This tumor was 3-4 cm in diameter. All nodes were negative. Patient's postoperative course was notable for heavy secretions which she had difficulty expectorating, requiring frequent suctioning and bronchoscopy several times with intubation 4x during these bronchoscopies. The patient was discharged on [5-27] and was stable until the day of admission, where she is noted to be confused by her family and having increasing shortness of breath with coarse breath sounds. 911 was called and the patient was found alert and oriented times three, but with O2 saturations on 5 liters (which was her discharge oxygen requirement) of 56%. She was brought to the Emergency Department, where the patient had progressive hypercapnic respiratory failure culminating in a intubation followed by hypotension which required wide open IV fluids and double pressors. The patient was subsequently brought to the Medical Intensive Care Unit for further treatment. PAST MEDICAL HISTORY: 1. Hypertension. 2. Multiple lung cancers, adenocarcinoma of the lung, negative nodes each time. 3. Chronic obstructive pulmonary disease with a FEV1/FVC preoperatively of 34%. 4. Skin cancer. 5. Cataracts. 6. Postoperative atrial fibrillation. 7. Peripheral neuropathy secondary to chemotherapy for the [2166] adenocarcinoma. HOME MEDICATIONS: 1. Protonix 40 mg po q day. 2. Digoxin 0.125 mg po q day. 3. Lopressor 25 mg po q day. 4. Humibid 1200 mg po bid. 5. Ciprofloxacin 500 mg po bid. 6. [First Name5 (NamePattern1) 233] [Last Name (NamePattern1) 1002]. 7. Verapamil SR 120 mg po q day. 8. Xanax 4 mg po bid. 9. Combivent three puffs qid. 10. Flovent three puffs [Hospital1 ]. 11. Foradil one capsule [Hospital1 ]. ALLERGIES: Aminophylline causes nausea and vomiting. SOCIAL HISTORY: The patient lives with her husband. She ambulates with a walker since her discharge from [Hospital6 2911]. She has extensive tobacco history, but no alcohol or drug use. PHYSICAL EXAMINATION: On presentation, the patient had the following physical exam: Her temperature is 97.0, heart rate is 95 and regular, blood pressure was 143/78 on dopamine and Neo-Synephrine. She was on assist control 18/500, 100% FIO2, her PEEP was 10, her peak pressure is 33, plateau pressure is 24, and she was sating roughly 94%. In general, she is an elderly female intubated and sedated. HEENT: Pupils are equal and reactive to light, anicteric. Neck was supple. There was bounding bilateral carotid upstrokes, no bruits, no lymphadenopathy. Cardiovascular: Distant heart sounds, regular, rate, and rhythm, prominent pulsation at the right upper sternal border. There was a S4, there were no murmurs or rubs. Lungs: She had decreased breath sounds at the left lower lobe, although is moving okay air. Abdomen: Abdomen is soft, nontender, nondistended, no masses, no hepatosplenomegaly, and normal bowel sounds. Extremities: 1+ pitting edema all four extremities, multiple ecchymoses on all four extremities with faint macular rash on thighs. She had a laceration roughly 8 cm in the left forehand. The left hand was dusky, and her fingers were cool to touch. Neurologically, she was moving both feet with normal tone. The day of discharge, the patient's physical examination was as follows: Her temperature is 98.8, heart rate was 81 and regular, blood pressure is 129/61. She was sating 96%. She was on pressure support of 10 and 5, tidal volume 400, respiratory rate of 20, and FIO2 is 40%. She was supine. She appeared depressed the day of discharge. She was still anicteric. Neck is supple. Heart is regular, rate, and rhythm. Lungs showed inspiratory wheezes bilaterally, rhonchi in the right lower lobe. Abdomen is soft with mild tenderness to palpation around the PEG site. Her extremities were 3+ edema in the lower extremities and 1+ in the upper extremities. She had multiple ecchymoses. The laceration on the left forearm was dressed and her trache site was clean, dry, and intact. LABORATORIES: Laboratory data on admission, the patient had the following laboratories: White count is 10.3, hematocrit 30.0, platelets 448, and MCV of 85. She had 88% polys, 1 band, 7% lymphocytes, 0% monocytes. Her Chem-7 was as follows: Sodium 141, potassium 5.4, chloride 100, bicarb 32. BUN 19, creatinine 0.6, glucose 170, calcium 9.2, magnesium 1.9, phosphorus 5.0. Her coags were 13.1, 27.1 with an INR of 1.1. Her lactate level was 1.0. She had a chest x-ray which showed cardiomegaly, pleural thickening with volume loss in the right, patchy density in the lower up and mid right lower lobe. She had sutures in the left mid lung. She had a loculated right pleural effusion versus infiltrate. She had left lower lung collapse, small nodular density in the left apex, healed posterior rib fractures on the left. Sputum from the outside hospital on [4-30]: Her bronch had grown [Female First Name (un) 564]. Bronch on the 12th had grown out Acinetobacter baumannii pansensitive. On the 15th, she had gram-negative rods and [Female First Name (un) 564] albicans, and on the 17th, she had gram-negative rods. Her culture data here at [Hospital3 ] was all negative including multiple blood cultures and urine cultures. Her sputum did grow out 4+ gram-positive cocci in pairs, but no predominance of a pathogen. Electrocardiogram initially showed 58 beats per minute accelerated junctional rhythm, normal axis and normal intervals, but the P-R was not clearly seen and there was a question of whether there was AV beat association. The patient had CT scan of the chest which showed a right hydropneumothorax at the upper lobe on the right, right lower lobe fibrosis, consolidation, small right effusion, and a left sided bullae with minimal effusion. Patient also had an echocardiogram which demonstrated the [Name Prefix (Prefixes) ] [Last Name (Prefixes) 3841] dilated, left ventricular ejection fraction of greater than 55%, RV was dilated, there was a right ventricular pressure overload into her pulmonary artery systolic hypertension, 2+ mitral regurgitation, and 2+ tricuspid regurgitation. The day of discharge the patient had the following laboratory values: Her white count is 16.8, roughly 93% polys and 5% lymphocytes, hematocrit 33.0. Chem-7: 140 of sodium, potassium 3, chloride 99, bicarb 31, BUN 28, creatinine 0.3, glucose 122. Calcium 8.2, magnesium 1.6, phosphorus 4.0. HOSPITAL COURSE: 1. Pulmonary: The patient came in with hypercapnic respiratory failure. It was felt that the likely etiology of the respiratory was as follows: She has extremely poor underlying lung disease with minimal lung reserve. Given the multiple resections of her lungs and severe chronic obstructive pulmonary disease and bullous disease. It was felt that she had copious secretions again. On her discharge from [Hospital6 ], lately had some mucus plugging and then had respiratory fatigue which led to the hypercapnic respiratory failure. In addition, she had the right lower lobe consolidation and her right hydropneumothorax which predominantly played roles in her respiratory distress. She had 100 cc of clear yellow fluid drained from an effusion on the right lower lobe, but this was not in communication with the hydropneumothorax and remainer of the fluid was not drained. The fluid was not sterile. The patient was kept on the ventilator, and although she had a RSBI and tolerated pressure support well when she was extubated, she required continuous mask ventilation, and after a day and a half, the patient asked to be reintubated. She was subsequently reintubated, and then [Hospital6 1834] elective tracheostomy two days prior to discharge after she tolerated the pressure support well. However, the patient continued to have heavy secretions and [Hospital6 1834] bronchoscopy which demonstrated these copious secretions, but no further acute pulmonary processes. The patient was maintained on albuterol and Atrovent nebulizers q6h prn, and albuterol and Atrovent metered-dose inhalers q4h around the clock. She was treated for the right lower lobe infiltrate with levofloxacin which is day #9 on the day of discharge with a total of 14 day course for presumed pneumonia. The patient had also been on high dosed steroids presumably for her chronic obstructive pulmonary disease at the outside hospital. She was continued on hydrocortisone taper and on the day of discharge from [Hospital3 ], her hydrocortisone was discontinued, and she was started on 10 mg of prednisone po q day. The patient was seen by Thoracic Surgery, and although initially they were questioning the need to have the right hydropneumothorax drained, they mentioned this was not likely contributing significantly to her lung disease and did not need drainage. 2. Cardiovascular: On admission, the patient had an accelerated junctional rhythm and had a history of postoperative atrial fibrillation. She during the course of her hospital stay after initial intubation dropped her pressures and required two pressors to support her blood pressure. These pressors were rapidly weaned within 24 hours and her blood pressure remained stable for the duration of her hospital course. However, the patient had episodes of atrial fibrillation with rapid ventricular rate and multiple pauses exceeding five seconds at length at 3x during her hospital stay. At one time, the patient went into atrial fibrillation with a rapid ventricular rate, was treated with diltiazem, and subsequently cardioverted. After the cardioversion, the patient became asystolic, was treated with Epinephrine and atropine, and reverted to normal sinus rhythm. The patient was seen by the Electrophysiology service, and they determined that the patient had severe sinus node dysfunction along with A-V node dysfunction. All nodal blocking agents should be avoided in this patient, and although she was a candidate for a permanent pacemaker given her sinus node dysfunction and long pauses, the patient deferred this procedure now, and should be re-evaluated as an outpatient. The patient on hospital day #4, had increase in her blood pressure to probably her baseline hypertensive level. She was initially treated with IV hydralazine and on the day of discharge was switched to lisinopril 5 mg po q day. Again all nodal blocking agents should be avoided in this patient. 3. Infectious disease: The patient had all negative culture data during her hospital stay and she was treated only for the right lower lobe infiltrate with levofloxacin. She had intermittent low grade fevers the last 24 hours prior to discharge at 100.3. 4. Gastrointestinal: The patient was not able to take po and J-tube through the hospital stay. Two days prior to discharge, she had a percutaneous enterogastrostomy tube placed and tolerated tube feeds well. There were no other gastrointestinal issues. 5. Dermatology: The patient has extremely friable skin presumably from long steroid use. She had a laceration on the left forearm which was seen by Plastic Surgery and they recommended wet-to-dry dressings, but no suturing. The patient also had a faint macular rash on presentation, which faded after two days presumed secondary to probably the ciprofloxacin that she had received as an outpatient. 6. Endocrine: The patient does not have a history of diabetes. She had elevated blood sugars during her hospital stay presumably due to the stress and given hydrocortisone. She was treated with regular insulin-sliding scale [Hospital1 ]. 7. Psychiatric: The day prior to discharge, the patient related feeling depressed and was started on Zoloft for her depression. CONDITION ON DISCHARGE: Fair. DISCHARGE STATUS: To [Hospital6 310]. DISCHARGE DIAGNOSES: 1. Status post right upper lobe resection for adenocarcinoma of the lung with severe underlying chronic obstructive pulmonary disease and poor pulmonary reserve. 2. Sick sinus syndrome and tachy-brady. The patient is a candidate for a pacemaker. As an outpatient, she should avoid all nodal blocking agents. 3. Right lower lobe pneumonia. 4. Preload dependence. 5. Depression. 6. PEG placement. DISCHARGE MEDICATIONS: 1. Colace 100 mg PEG tube [Hospital1 ]. 2. Pantoprazole 40 mg PEG tube q24. 3. Levofloxacin 500 mg PEG tube q24 day #9 of 14, the last day should be [2173-6-15]. 4. Combivent MDI q4h two puffs. 5. Albuterol and Atrovent nebulizers q6h prn. 6. Regular insulin-sliding scale [Hospital1 ]. 7. Lisinopril 5 mg po q day. 8. Prednisone 10 mg po q day. 9. Heparin subQ 5,000 units q8h. 10. Furosemide 40 mg po bid. 11. Potassium [First Name5 (NamePattern1) 233] [Last Name (NamePattern1) 1002] 20 mEq po q day to be titrated daily. 12. Aspirin 325 mg po q day. 13. Acetaminophen prn. 14. Morphine sulfate 1 to 5 mg IV q4 prn pain at PEG site. FOLLOW-UP PLANS: 1. The patient is to call the Electrophysiology Clinic at [Hospital3 ] for consideration of a permanent pacemaker upon discharge from [Hospital1 ]. 2. The patient should also call the Pulmonary Clinic at [Hospital1 1444] for a follow-up appointment within two weeks of discharge from [Hospital1 ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. Dictated By:[Last Name (NamePattern1) 11801] MEDQUIST36 D: [2173-6-10] 11:53 T: [2173-6-10] 12:26 JOB#: [Job Number 47959] cc:[Telephone/Fax (1) 47960] Name: [Known lastname 8870], [Known firstname ] Unit No: [Numeric Identifier 8871] Admission Date: [2173-6-2] Discharge Date: [2173-6-10] Date of Birth: [2099-6-11] Sex: F Service: ADDENDUM: The patient grew gram negative rods from her urine culture. The identification and sensitivities of the organism are pending. However, the patient developed this infection on Levofloxacin which she had been taking for nine days prior. Therefore the presumption was that this is pseudomonal or resistant organism and the patient was started on Aztreonam 1 gm q. 8 hours. The patient should receive seven days of this, the last day which should be [2173-6-16]. On [6-11], Friday morning, Dr. [Last Name (STitle) ] will call [Hospital1 ] and report identification sensitivities of the organisms so that they may adjust antibiotics appropriately. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5451], M.D. [MD Number(2) 5452] Dictated By:[Last Name (NamePattern1) 5934] MEDQUIST36 D: [2173-6-10] 14:08 T: [2173-6-10] 15:14 JOB#: [Job Number 8872]	[ "496", "V10.11", "486", "599.0", "511.8", "518.81", "427.81", "458.9", "263.9" ]	icd9cm	[ [ [] ] ]	[ "31.1", "34.91", "96.6", "96.04", "96.72", "43.11", "33.23" ]	icd9pcs	[ [ [] ] ]								13042, 13440	13463, 14120					7694, 12945																3285, 7677				2557, 3005										3222, 3269					14137, 15939							160, 182							211, 2185																	2207, 2539	3022, 3199	12970, 13021
54,741	153,749	8959	Discharge summary	report	Admission Date: [2166-8-22] Discharge Date: [2166-8-31] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2290] Chief Complaint: Unresponsive, respiratory distress Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a [Age over 90 ] year old female with a history of dementia, multiple ischemic strokes, hypertension, diabetes mellitus, atrial fibrillation, and diastolic CHF who was found unresponsive in bed at her nursing home. She was not responsive to voice and only minimally responsive to sternal rub. She was noted to be in respiratory distress with tachypnea and desaturation on RA, and was placed on a NRB. She was brought to the [Hospital1 18] ED for further evaluation. She has a documented DNI/DNR order. . In the ED, initial vital signs were T 96.9, BP 110/73, HR 130, RR 24, SpO2 100% on 15L NRB. She had an unremarkable head CT with only no acute process noted. Portable CXR showed a LLL opacity concerning for infection, and her WBC count was elevated to 16.4 with 79.3% neutrophils and no bands. UA showed WBC 13, small leuk esterase, and no bacteria. Her Troponin was slightly elevated to 0.05, and EKG showed atrial fibrillation at 135 bpm with left axis deviation and no acute ischemic changes. Oral secretions were cleared with suction. She was given Vancomycin 1000 mg IV and Zosyn 4.5 grams IV. She received a total of 700 ml IV fluids. For her atrial fibrillation, she received a total of Diltiazem 40 mg IV with good response in her heart rate and stable blood pressure. She was admitted to the ICU given her continued oxygen requirement. Vitals prior to transfer were T afebrile, HR 103, BP 97/47, RR 27, SpO2 98% on 15L. . Once in the ICU, she remained unresponsive to voice and would only withdraw from painful stimuli. She was in mild respiratory distress with tachypnea and appeared uncomfortable. Her son was [Name (NI) 653] and her code status was confirmed as DNR/DNI. He will be coming in to the ICU tomorrow. . Review of Systems: Unable to obtain due to patient mental status. Past Medical History: (per limited nursing home records sent on transfer) # Dementia # Multiple ischemic strokes # Aphasia # Dysphagia -- Tube feeds through G-tube -- Jevity 1.2 at 60 ml/hr -- Free water flushes 250 ml Q6H -- Flush 50 ml before and after meds # Hypertension # Diabetes mellitus # Atrial fibrillation # Congestive Heart Failure -- unclear if systolic or diastolic # Recent admission to [Hospital1 112] from [2166-7-18] to [2166-7-31] Social History: Unable to obtain due to patient mental status Family History: Unable to obtain due to patient mental status Physical Exam: ADMITTING PHYSICAL EXAM: Vitals: T 98.8, BP 112/67, HR 116, RR 22, SpO2 100% on 15L NRB General: Unresponsive, withdraws to pain. Moderate respiratory distress, otherwise appears comfortable. HEENT: Sclera anicteric, PERRL, dry MM Neck: JVP not elevated, no LAD Lungs: Decreased breath sounds and rhonchi at left base. Coarse breath sounds throughout. CV: Irregularly irregular and mild tachycardia. Normal S1, S2. No murmurs, rubs, gallops. Abdomen: Bowel sounds present. G-tube and abdominal binder in place. Soft, non-tender, non-distended. GU: Foley draining clear yellow urine Ext: Cool distal extremities. Radial pulses 1+, unable to palpate pedal pulses. No lower extremity edema. Toes somewhat cyanotic. . DISCHARGE PHYSICAL EXAM: Afebrile BP 100s-110s/50-60s P 50s-80s RR 20 SpO2 96-100% RA Gen: mostly nonverbal and unresponsive. Usually with eyes open. Occasionally will turn to voice. Otherwise, does not withdrawl to pain and does not follow commands. Remainder of exam is unchanged except heart rate was well controlled at time of discharge. Pertinent Results: ==================== Imaging: ==================== # CHEST (PORTABLE AP) ([2166-8-22] at 12:32 PM): FINDINGS: A portable semi-upright view of the chest was obtained. The patient is rotated and low lung volumes result in bronchovascular crowding. Left lower lung consolidatoin may be a combination of atelectasis and effusion, although infection cannot be excluded. The heart is enlarged. Aortic knob calcifications are seen. The right lung is clear without pneumothorax or effusion. No acute osseous abnormality is identified. IMPRESSION: Left lower lung consolidation may be a combination of telectasis and effusion, but infection cannot be excluded. PA and lateral views may be helpful for further evaluation. . # CT HEAD W/O CONTRAST ([2166-8-22] at 12:38 PM): FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect or major vascular territorial infarcts. Prominent ventricles and sulci are compatible with moderate global age-related volume loss. Hypoattenuation in the periventricular and subcortical white matter is likely sequelae of chronic microvascular ischemic disease. Bilateral basal ganglia calcifications are noted. There is no shift of normally midline structures. [Doctor Last Name ]-white matter differentiation is preserved. No acute osseous abnormality is identified. Mild mucosal thickening is seen in the ethmoid air cells and sphenoid sinuses. The mastoid air cells are clear. IMPRESSION: No acute intracranial hemorrhage. Significant global age related volume loss and chronic microvascular ischemic disease change. . CHEST (PORTABLE AP) Study Date of [2166-8-26] FINDINGS: As compared to the previous examination, the extent of the pre-existing left pleural effusion has moderately increased. The effusion now occupies approximately 50% of the left hemithorax. No right pleural effusion. There is mild cardiomegaly with signs of minimal overhydration. No newly occurred focal parenchymal opacities. Extensive left lower lobe atelectasis. ==================== Micro: Blood and urine cultures negative with exception of yeast from urine culture from admission. . ==================== DISCHARGE LABS: [2166-8-31] 06:45AM BLOOD WBC-5.8 RBC-3.63* Hgb-10.8* Hct-33.0* MCV-91 MCH-29.8 MCHC-32.7 RDW-13.1 Plt Ct-395 [2166-8-31] 06:45AM BLOOD Glucose-295* UreaN-27* Creat-1.1 Na-138 K-3.7 Cl-95* HCO3-31 AnGap-16 [2166-8-31] 06:45AM BLOOD Calcium-9.0 Mg-2.4 Brief Hospital Course: The patient is a [Age over 90 ] year old female with a history of dementia, multiple ischemic strokes, hypertension, diabetes mellitus, atrial fibrillation, and diastolic CHF who was found unresponsive in bed and in respiratory distress at her nursing home, likely due to a left lower lung pneumonia. . # Pneumonia, likely aspiration - She has a history of dementia and dysphagia and was receiving tube feeds through a percutaneous G tube. Given her acute presentation and history, an aspiration event was presumed to be the likely cause of her respiratory decompensation. She was started on Vancomycin and Zosyn in the ED, and required supplemental oxygen with a 15L NRB. She was continued on Vanc/Zosyn in the ICU. She completed an 8-day course of Vancomycin and Zosyn on [2166-8-29]. . # Acute on chronic diastolic heart failure - On the medical floor, she had an acute decompensation, with increased respiratory distress, Afib with HR to 130's, and decreased breath sounds. She was presumed to be in acute diastolic heart failure, and was treated with IV lasix, IV diltiazem, as well as IV morphine and ativan for patient comfort given acute distress. With these interventions, pt's respiratory status stabilized. Her HR improved significantly, and she was started on low dose diltiazem to continue to help control her heart rate. She was continued on oral lasix. Her volume status should be monitored carefully. Also, would recommend that her electrolytes and creatinine are checked every few days and that her lasix be decreased if her creatinine increases. . # Atrial Fibrillation, with RVR - She was in RVR several times during her hospitalization and her nodal blockade was titrated. Her heart rate was very well controlled on diltiazem and metoprolol at the current doses (please see discharge medication list). . # ? upper GI bleed - On [8-28] she was noted by nursing to have bright red blood when her G-tube was suctioned. Tube feeds were held, she was started on an intravenous PPI drip and her hematocrit was trended. A conversation was held with her health care proxy who declined endoscopy or intervention. Ultimately, her hematocrit was trended and actually remained stable. Her proton pump inhibitor was changed to oral. Her tube feeds were restarted and she was tolerating them at full strength at the time of discharge without residuals or any evidence of bleeding. . # Mental Status Changes/ probable toxic metabolic encephalopathy: She has a history of dementia and prior strokes. Her baseline prior to the current admission was poor after her most recent stroke per her son, with aphasia and dysphagia noted in her records. Head CT on arrival did not show any acute process. During the admission, she was generally minimally responsive, and aphasic. She would occasionally orient towards voice but that was about the extent of her responsiveness. . # Troponin Leak: Her Troponin was elevated slightly to 0.05 on admission with no ischemic changes on EKG. This was most likely due to demand ischemia due to Afib with RVR. Troponins were followed and stably elevated 0.05. . # Nutrition: She is on tube feeds with Jevity 1.2 at 60 ml/hr at home through her G-tube. . # Diabetes Mellitus: Fingerstick checks Q6H. She was managed with a regular insulin sliding scale and this should be continued . # Goals of care: A family meeting was held with pt's son and healthcare proxy, [Name (NI) 915] [Name (NI) ], on [2166-8-26], shortly after a period of acute decompensation. Palliative care was consulted and assisted with goals of care discussions. Per the discussion with [Doctor Last Name 915], future ICU transfers are not within patient's goals of care. Futhermore, we recommend further discussion with her nursing facility physician, [Name10 (NameIs) 3] it appears that the family is open to discussion about the possibility of no further hospitalizations, and instead pursuing comfort-directed care within the nursing home. She currently remains DNR/DNI, no ICU care. ****************** TRANSITIONAL ISSUES: - Son [Name (NI) 915] [Name (NI) ] tel #s: (h)[Telephone/Fax (1) 31105]; (c) [Telephone/Fax (1) 31106] - please continue discussions with family about goals of care as family is potentially interested in not hospitalizing for further exacerbations of health. - please monitor electrolytes including creatinine at least several times a week and consider decreasing lasix as needed - please monitor finger sticks, she may need a change in tube feeds or starting NPH for improved glycemic control Medications on Admission: Aspirin 325 mg PO daily Pravastatin 20 mg PO daily Dalteparin 5000 units SC daily Metoprolol 25 mg PO BID Furosemide 40 mg PO BID Novolog sliding scale Acetaminophen 650 mg PO Q4H PRN pain or fever (max 4g /24 hours) Trazodone 25 mg PO QHS Colace 100 mg PO daily Senna 8.6 mg PO daily PRN constipation Bisacodyl 10 mg PR daily PRN constipation Fleet enema PR daily PRN constipation Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Telephone/Fax (1) ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. insulin regular human 100 unit/mL Solution [Telephone/Fax (1) ]: see other instructions units Injection every six (6) hours: 70-100 give nothing 100-150 give 2 units of regular 150-200 give 4 units of regular 200-250 give 6 units of regular 250-300 give 8 units of regular 300-350 give 10 units of regular >350 [Name8 (MD) 138] MD . 3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Name8 (MD) ]: One (1) neb Inhalation Q4H (every 4 hours) as needed for wheezing. 4. furosemide 40 mg Tablet [Name8 (MD) ]: Two (2) Tablet PO DAILY (Daily). 5. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 6. metoprolol tartrate 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q6H (every 6 hours). 7. diltiazem HCl 90 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [Hospital ] Healthcare Center - [Location (un) ] Discharge Diagnosis: # Pneumonia, likely aspiration # Acute Respiratory Distress # Acute on chronic diastolic heart failure # Atrial Fibrillation with RVR # Cardiac ischemia (demand ischemia) # Advanced Dementia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted with unresponsiveness and hypoxia. You are suspected of having a pneumonia and acute diastolic heart failure. You were treated in the ICU initially, and you received antibiotics for your pneumonia. You had a fast heart rate and fluid in the lungs, which was treated with medications. We had a discussion with your son and healthcare proxy ([Name (NI) 915] [Name (NI) ]), and it was decided that ICU care would not be within your future goals of care. Based on this discussion, your family should also talk with the doctors at your nursing facility about future goals of care, and whether you would want hospitalization in the future, or if you would prefer to remain in the nursing facility and be made comfortable, if you becomes ill again. Followup Instructions: Please follow-up with your primary care doctor [First Name (Titles) ] [Last Name (Titles) **] from the extended care facility	[ "799.02", "507.0", "428.33", "428.0", "290.40", "707.22", "V49.86", "518.81", "578.9", "437.0", "427.31", "349.82", "250.00", "V44.1", "V64.2", "V49.84", "707.03" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	12424, 12507	6299, 10367	286, 292	12742, 12742	3855, 5996	13673, 13808	2707, 2755		11333, 12401		12528, 12721		10926, 11310				12878, 13650					6012, 6276								2795, 3489																		10388, 10900			2114, 2163					212, 248							320, 2095											12757, 12854						2185, 2627	2643, 2691						3514, 3836
9,097	188,872	51703+59374	Discharge summary	report+addendum	Admission Date: [2176-3-11] Discharge Date: [2176-3-28] Service: C-MED HISTORY OF PRESENT ILLNESS: This is an 88-year-old male with a history of congestive heart failure with multiple severe valvular problems including aortic stenosis, tricuspid regurgitation as well as mitral regurgitation, biventricular dilatation, also status post VVIR pacemaker for atrial fibrillation and tachy-brady syndrome who presents with a 25 pound weight gain over the last month. As per the patient, he used to weigh 170 pounds and currently weighs 204 pounds. The patient states that his Toprol was discontinued about two weeks ago and he was started on Coreg and since then feels that his condition has worsened over the past three weeks prior to admission. The patient states that he also did have a rib fracture about three weeks ago and his overall worsening of his condition has coincided with the rib fracture. The patient also says that his abdominal girth has increased throughout this time as well. The patient says that his lower extremities have bilaterally also become more swollen and that his ambulation has decreased. The patient also admits to orthopnea and says that he must sleep in a chair. He denies paroxysmal nocturnal dyspnea, denies any respiratory changes. The patient denies any recent febrile illnesses, as well as chest pain. PAST MEDICAL HISTORY: 1. Congestive heart failure, history of group B endocarditis three years ago with severe mitral regurgitation, moderate aortic stenosis with a peak gradient of 34, 3+ tricuspid regurgitation, mild aortic regurgitation, elevated PA pressures of 37 mmHg, dilated left ventricle as well as dilated ascending aorta, right ventricular dilation and depressed ejection fraction of approximately 40, left atrial enlargement. 2. Atrial fibrillation status post VVIR pacemaker secondary to tachy-brady syndrome. The patient was originally admitted for syncope in [2171]. 3. Transurethral resection of the prostate. 4. Status post bilateral hip redo replacement as well as left hip fracture at age 20. 5. Status post inguinal hernia repair 6. Chronic renal insufficiency, baseline creatinine of 1.5 to 2.0 with hyperkalemia and hyperuricemia 7. Macular degeneration 8. Lactose intolerance 9. History of zoster in [2169] 10. Left cataract 11. Status post cholecystectomy [86]. Multinodular goiter 13. Status post recent fall with rib fracture 14. Remote head injury ALLERGIES: PENICILLIN, CODEINE AND AMBIEN ADMISSION MEDICATIONS: 1. Coreg 1.612 once a day 2. Aldactone 12.5 once a day 3. Digoxin 0.0625 once a day 4. Lasix 40 twice a day 5. Zestril 2.5 once a day 6. Coumadin 2.5 mg on Tuesday, Wednesday, Thursday, Saturday, Sunday and 5 mg on Monday SOCIAL HISTORY: The patient lives with his wife at home with home [Name (NI) 269] and home care services. FAMILY HISTORY: Noncontributory PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: The patient was afebrile, blood pressure 130/70, heart rate 70, respiratory rate 18, O2 saturation 96% on room air. GENERAL: The patient was pleasant in no apparent distress lying in bed at about 20?????? above the horizontal. HEAD, EARS, EYES, NOSE AND THROAT: Sclerae are anicteric. He had a left surgical pupil. NECK: Jugular venous pressure of approximately 12 cm wider with a positive hepatojugular reflux. No bruits or lymphadenopathy was appreciated. CHEST: Clear to auscultation with bibasilar deep inspiratory crackles. CARDIOVASCULAR: Regular rate and rhythm, [3-27] holosystolic murmur at the left lower sternal border radiating to the apex, [2-28] right upper sternal border systolic ejection murmur. ABDOMEN: Distended. There was a positive fluid wave. There was midline diaphysis and an umbilical hernia. There were no abdominal bruits. There were positive bowel sounds. Liver span was approximately 10 cm in the midclavicular line. EXTREMITIES: 4+ edema up to the thighs, as well as perirectal edema and sacral edema. There was no evidence of any skin breakdown. NEUROLOGIC: The patient was awake, alert and oriented x3. Cranial nerves II through XII were intact. LABORATORY VALUES ON ADMISSION: White blood cells 6.5, hematocrit 34.7, platelets 126. Sodium 140, potassium 4.6, chloride 106, bicarbonate 23, BUN 74, creatinine 2.3, blood sugar 165. PT 20, INR 2.8, PTT 37.2, ALT 19, AST 22, alkaline phosphatase 168 and total bilirubin 1.3. HOSPITAL COURSE: 1. CARDIOVASCULAR: In the first week of the [Hospital 228] hospital stay, he was gently diuresed due to low systolic blood pressures ranging from the 90s to 120s and slowly increasing creatinine. Initially, the patient's INR was elevated at 3.5. This was allowed to drift down for the patient to undergo cardiac catheterization. On the [9-15], the patient underwent cardiac catheterization which showed clean coronaries. Aortic valve gradient was between 10 and 14 mmHg consistent with mild aortic stenosis. Cardiac index of 1.82 which improved to 2.34 with milrinone. The patient had a blood pressure of 27 with prominent V waves. Subsequently, the patient was transferred to the CCU for hemodynamic monitoring during diuresis. During the [Hospital 228] hospital stay in the CCU, the patient was diuresed with the help of milrinone. Approximately 3 to 4 liters were taken off while in the CCU with Swan present. On milrinone, the patient's PA pressures were 38/25. Cardiac output was 6.7. Cardiac index was 3.18. The patient's creatinine was improved to 1.9 on the milrinone while in the CCU the patient was also evaluated by cardiac surgery for valve repair. The cardiac surgeons felt that the patient had multiple comorbidities and that the risk of surgery would be high, approximately 30% mortality and the patient was not a suitable surgical candidate for valve repair. On the [9-17], the patient had an episode of slurred speech and difficulty finding a word at that time and a neurology consult was obtained who recommended CT of the head without contrast. At that time, CT of the head was done which showed mild atrophy and a small 6 mm colloid cyst in the midline near the foramen of [Last Name (un) 2044], minimally dilated ventricles. No intracranial hemorrhage was seen. Subsequently, the patient was transferred back to the C-MED service on the floor. At that time, it was felt that the patient's neurologic status was stable. The patient started to complain of bilateral leg pain in the setting of 3 to 4 liters of diuresis. Uric acid level was drawn and was found to be elevated at 13. The patient was started on colchicine for acute gout and responded well. While on the floor, the patient was not able to diuresed on 80 intravenous of Lasix [Hospital1 ]. The dose of Lasix was subsequently increased to 150 mg intravenous [Hospital1 ] as well as the addition of Zaroxolyn 2.5 mg po bid. The patient responded well and diuresed approximately 1 to 2 liters a day while on the floor on that regimen. This was complicated by a rising creatinine, originally down to 1.7 after transfer from the CCU to approximately 2.2 while on the floor, which is approximately the same creatinine that the patient was admitted with. While on the floor, the patient was evaluated by the electrophysiology service for several episodes of nonsustained ventricular tachycardia. They recommended starting amiodarone initially at 400 mg [Hospital1 ] and then switching to 400 mg po qd to suppress the ventricular tachycardia and they also recommended upgrading of the patient's VVI pacer to a biventricular pacemaker. The patient had an upgrade of his pacer on the [8-26] in the electrophysiology lab. Subsequently, the patient was transferred back to the C-Med floor in stable condition with a functioning biventricular pacer as well as improved blood pressure with the biventricular pacer. Subsequently, the patient was reevaluated by the physical therapy service who felt he would be a good candidate for rehabilitation. The patient was discharged back to rehabilitation in stable condition. Of note, the patient had an echocardiogram on the [9-9] which showed left atrium was markedly dilated, right atrium markedly dilated, severe symmetric left ventricular hypertrophy, normal LV cavity size, mild global LV hypokinesis with marked hypokinesis of the anterior septal and nasal walls with moderately depressed systolic function. The aortic root was mildly dilated. Aorta was mildly dilated. Aortic valve leaflets were thickened and deformed. Mild aortic regurgitation and moderate possibility of severe aortic valve stenosis, mitral valve with severe 4+ mitral regurgitation, severe 4+ treated and released and mild PA hypertension. DISCHARGE CONDITION: Stable DISCHARGE STATUS: Rehabilitation DISCHARGE MEDICATIONS: 1. Amiodarone 400 mg po qd 2. Ciprofloxacin 250 mg po bid 3. Bumex 6 mg po q a.m. and 4 mg po q p.m. 4. Zaroxolyn 2.5 mg po bid to be given 30 minutes prior to the Bumex 5. Captopril 12.5 po tid 6. Protonix 40 mg po qd 7. Enteric coated aspirin 325 mg po qd 8. Coumadin 2.5 mg po qd The patient's weight upon discharge was 83.6 kg. The patient's blood pressure upon discharge was 110/54. The patient's creatinine upon discharge was 2.3. DISCHARGE DIAGNOSES: 1. Congestive heart failure 2. Status post biventricular pacer 3. Atrial fibrillation 4. Chronic renal insufficiency 5. Macular degeneration 6. Status post cholecystectomy 7. Status post bilateral hip replacements 8. Dilated cardiomyopathy secondary to valvular disease 9. Gout [Name6 (MD) ] [Last Name (NamePattern4) 5467], M.D. [MD Number(1) 5468] Dictated By:[Name8 (MD) 9784] MEDQUIST36 D: [2176-3-28] 07:16 T: [2176-3-28] 07:14 JOB#: [Job Number 34139] Name: [Known lastname ], [Known firstname 657] Unit No: [Numeric Identifier 17496] Admission Date: [2176-3-28] Discharge Date: [2176-4-2] Date of Birth: [2088-2-4] Sex: M Service: [Hospital Unit Name 319] ADDENDUM TO HOSPITAL COURSE: After the patient receied a biventricular pacemaker, the patient had an uncomplicated hospital course other than mild elevation in his serum creatinine which was likely related to aggressive diuresis, the patient had his dose of Bumex subsequently adjusted and lowered, and the patient's Lasix was discontinued. With diuresis, the patient's creatinine had peaked at 2.8, and subsequently prior to discharge back to [Location (un) 176], had gone down to 2.3. Also the patient was loaded with Coumadin after the biventricular was traced, and had a therapeutic INR prior to transfer to [Hospital 176] Rehab. The patient's discharge medications included: 1. Amiodarone 400 mg po q day. 2. Bumex 30 mg po q day. 3. Coumadin 1 mg po q day. 4. Zestril 5 mg po q day. 5. Protonix 40 mg po q day. 6. Enteric coated aspirin 325 mg po q day. It was felt that a low-dosed beta blocker would be of benefit once the patient was an outpatient. PATIENT'S DIET: The patient's diet was low sodium 1200 cc fluid restriction, lactose free, renal. DISCHARGE DIAGNOSES: 1. Congestive heart failure, ejection fraction 40% with 4+ mitral regurgitation, status post biventricular pacemaker. 2.Tachy-brady syndrome status post biventricular pacemaker. 3. Atrial fibrillation. 4. Bilateral hip replacements. 5. Chronic renal insufficiency with a baseline creatinine of 2.0. 6. Macular degeneration. 7. Status post recent rib fracture. 8. History of hearing loss. DISCHARGE STATUS: To [Hospital 176] Rehabilitation. DISCHARGE CONDITION: Stable. FOLLOWUP: Follow up was with the patient's cardiologist, Dr. [First Name8 (NamePattern2) 890] [Name (STitle) 690] within 1-2 weeks after discharge. [Name6 (MD) ] [Last Name (NamePattern4) 8732], M.D. [MD Number(1) 8733] Dictated By:[Name8 (MD) 1685] MEDQUIST36 D: [2176-10-25] 13:21 T: [2176-10-28] 03:45 JOB#: [Job Number 17497]	[ "427.31", "398.91", "425.4", "593.9", "789.5", "599.0", "274.9", "396.2", "784.5" ]	icd9cm	[ [ [] ] ]	[ "37.87", "37.23", "88.56", "37.76" ]	icd9pcs	[ [ [] ] ]				11692, 12109			2887, 2925	11223, 11670	8848, 9297					10160, 11202					2529, 2758																																												118, 1363									4189, 4437								1385, 2506	2775, 2870
19,590	162,407	44846	Discharge summary	report	Admission Date: [2130-6-8] Discharge Date: [2130-6-14] Date of Birth: [2052-4-19] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 905] Chief Complaint: found down Major Surgical or Invasive Procedure: None History of Present Illness: 78M with diastolic CHF EF 45%, CAD s/p MI in [2122], PAF on coumadin, severe AS (valce area 0.8, peak gradient 55), epilepsy, DM-II, and elephantisis who presents after being found down by neighbors. The patient reports that he has difficulty ambulating at baseline and is chornically short of breath. The night prior to admission he reports waking up on the floor and unable to get up. He cannot recall falling or any particular symptoms prior to falling. He denies CP, DOE, or palpitations prior to falling. He denies incontinence or being excessively tired or weak after waking up. He denies hitting his head, only his L elbow. He denies past falls. He reports lying on the floor all night and was found when neighbors heard him calling. He endorses worsening SOB for several days after not taking lasix [3-13] difficulty getting to the bathroom. He reports that he had some fleeting, non-radiating, substernal CP during the night on the floor but no pain like his past MI. He reports some chills that night but no dysuria, cough, sputum production, or malaise. He also complains of chronic LE pain which is has had for 13 years but is no worse now. . Of note, he was hospitalized at [Hospital1 18] in [4-17] for COPD and CHF exacerbation [3-13] non-compliance with Lasix. He was diuresed and placed on fluid restriction. Lisinopril was decreased [3-13] hypotension and NTG was d/c'ed [3-13] AS. . In the ED his vital signs were Temp 97.8 HR 88 BP 123/60 RR12 Pox 98%. The patient complained of pain in his left arm, left knee, right knee as well as chronic SOB and no CP. He was given Unasyn and Vanc for cellultis. He was also given a 500mL bolus. EKG showed first degree AV conduction delay but no ischemia. His TnT was elevated with a low MB fraction and he was given ASA 325mg. He was admitted to the MICU for close monitoring. . In the MICU he was restarted on his Lasix with 40mg IV in place of his home dose of 80mg PO (which he may or may not have been taking). His antibiotics were changed to vancomycin and pip/tazo for a history of MRSA wound infection and Pseudomonas UTI. He improved clinically and did quite well. Of note, his phenytoin level was subtherapeutic at 2.1 and he was in [Last Name (un) ] with a Cr of 1.8 which fell to 1.4 overnight. His TnT rose to 0.74 from 0.30. His BNP was [Numeric Identifier ] from a baseline of 3792 in [4-17]. . At this time he reports ongoing orthopnea and SOB improved from prior to admission. He denies CP, F/C/SW, cough, or dysuria. He is speaking in full sentences and able to give his history, although complicated by poor English. . ROS: (+) see above (-) Denies fever, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Past Medical History: - Coronary artery disease, s/p MI, [2122] cath with 60% mid-lad, 70% diag - on aspirin and plavix. No stent documented at [Hospital1 18], but reported PCI at [Hospital1 112]. - Hypertension - Diastolic and systolic congestive heart failure, EF 45% 12/08. - Paroxysmal atrial fibrillation. - Moderate to severe aortic stenosis, 0.8-1.0 valve area, [1-16]. - COPD, Severe disease. - Tobacco abuse - Elephantiasis nostras verrucosa - Morbid obesity - OSA - Meningioma: s/p resection - Bladder tumor s/p resection at [Hospital1 112] [2126] - Epilepsy Social History: Lives [Doctor First Name ] in an apartment with VNA daily. 1.5 PPD tobacco x 40+ years. No etoh or illicits. Requires assisstance with some ADLs, ambulates from wheel chair to restroom/bed only. Family History: DM2, obesity Physical Exam: GEN: NAD, obese, no obvious cyanosis or pallor VS: 98.4 143/78 68 18 98% on 2L HEENT: MMM, no teeth, no OP lesions, no LAD, supple CV: RR, distant, NL S1, quiet S2, III/VI SEM loudest at the RUSB, JVP difficult to assess [3-13] habitus PULM: Diffuse high pitched wheezes but good air movement, decreased breath sounds at the L base, crackles at the R base, no ronchi ABD: Obese, BS+, NTND, no masses or HSM, no stigmata of chronic liver disease LIMBS: + clubbing, no cyanosis, ecchymosis of the L elbow, hematoma of the L antecubital fossa, 4+ LE edema bilaterally, knees TTP bilaterally with no erythema or warmth NEURO: No pronator drift, reflexes 1+ at the UE, moving all limbs . Pertinent Results: Admission labs: [2130-6-8] 12:00PM BLOOD WBC-22.7# RBC-3.69 Hgb-10.7* Hct-32.4* MCV-88 MCH-28.9 MCHC-33.0 RDW-15.1 Plt Ct-241 [2130-6-8] 12:00PM BLOOD PT-33.2* PTT-46.5* INR(PT)-3.5* [2130-6-8] 12:00PM BLOOD Glucose-177* UreaN-28* Creat-1.8* Na-135 K-5.0 Cl-99 HCO3-20* AnGap-21* [2130-6-8] 12:00PM BLOOD ALT-28 AST-171* LD(LDH)-687* CK(CPK)-7018* AlkPhos-88 TotBili-0.7 [2130-6-8] 12:00PM BLOOD CK-MB-33* MB Indx-0.5 cTropnT-0.30* proBNP-[Numeric Identifier ]* [2130-6-8] 12:00PM BLOOD Calcium-9.0 Phos-3.3 Mg-1.7 . Discharge labs: [2130-6-14] 07:56AM BLOOD WBC-11.3* RBC-4.05* Hgb-11.5* Hct-34.7* MCV-86 MCH-28.5 MCHC-33.2 RDW-14.6 Plt Ct-314 [2130-6-14] 07:56AM BLOOD PT-32.3* PTT-35.3* INR(PT)-3.4* [2130-6-14] 07:56AM BLOOD Glucose-138* UreaN-26* Creat-1.3* Na-140 K-3.5 Cl-98 HCO3-32 AnGap-14 [2130-6-14] 07:56AM BLOOD CK(CPK)-268* [2130-6-14] 07:56AM BLOOD CK-MB-3 cTropnT-0.51* [2130-6-14] 07:56AM BLOOD Calcium-9.3 Phos-3.2 Mg-1.9 . [2130-6-8] 3:14 pm URINE Site: CATHETER FINAL REPORT [2130-6-14] URINE CULTURE (Final [2130-6-14]): KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML.. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing species. SENSITIVITIES: MIC expressed in MCG/ML KLEBSIELLA OXYTOCA AMIKACIN-------------- <=2 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- R CEFTRIAXONE----------- R CEFUROXIME------------ R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- =>512 R PIPERACILLIN---------- R PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- <=1 S . CXR: diffuse pulm vasc prominence, mild cardiac congestion slightly worse than prior Right Knee: DJD, joint space narrowing, osteophytes, no fx or disclocation Left knee: DJD, no fractures Left Elbow: DJD, no fractures Brief Hospital Course: 78M with dCHF with EF45%, CAD s/p MI in [2122], PAF on coumadin, AS (valve area 0.8, peak gradient 55), COPD, elephantisis, eplipsy, and medication non-compliance who presents after being found down. Initially seen in the MICU. TnT fluctuated but CP free and no ECG changes. CKs initially elevated with low MB fraction consistent with some degree of rhabdomyolysis. [Last Name (un) ] resolved. SOB improved with nebs and diuresis. UTI ultimately grew ESBL Klebsiella. He was discharged on Bactrim to home with VNA after refusing rehab. . # Pyelynephritis: WBC 22 on admission. PNA vs cellulitis vs UTI vs septic joint. Abd benign and knee pain is stable and chronic. CXR more consistent with CHF exacerbation. LE edema believed to be [3-13] elphantiasis. UA consistent with UTI. UA positive with >50 WBC. BCx negative but febrile on admission. Initially received vancomycin, which was discontinued on transfer to Medicine. Continued Piperacillin-Tazobactam Na 4.5 g IV Q8H for empiric coverage of GNRs in urine until UCx grew Klebsiella with ESBL but sensitive to Bactrim. He was discharged on a total of 14 days of antibiotics. He was afebrile at discharge and clinically much improved. . # Troponin elevation: MB WNL, EKG unchanged, unlikely ischemic although Pt does have CAD and had transient CP x 1 this admission. Likely demand ischemia. On low dose Bblocker and ASA. . # SOB: CXR consistent with volume overload and elevated BNP. In the setting of Lasix non-compliance this is consistent with exacerbation of dCHF. Also has COPD, is producing sputum, and has wheezing. There is no infiltrate on CXR to suggest PNA. Improved with diuresis and was on room air at discharge. . # Acute on kidney injury: Cr 1.8 on admission from a baseline of 1.0-1.3. Etiology is CHF v volume depletion v rhabdomyolysis. Repidly improved the first night of admission to 1.4. Ulytes pre-renal on admission. Initially bolused in the MICU. Now s/p more aggressive diuresis with Cr stable around 1.0-1.3. Switched to home regimen of PO lasix and discharged on this. Restarted lisinopril once creatinine back at baseline. . # CAD: ASA, ACEI, and BBlocker as above. Discharged on Imdur 30 mg PO daily. Was on 60mg at home. . # Fall/Syncope: Unclear etiology, mechanical vs AS vs seizure, stroke unlikely with non-focal exam and rapid recovery. Pt may have had an arrhythmia. Dilantin subtherapeutic. Alb WNL. Continued with home regimen as compliance may have more to do with this than dose. . # Elephantitis: Chronic, followed by derm. No effusion or warmth around his knees. Wound care consulted actively. Abx as above would have covered any cellulitis. Continued home regimen of Domeboro 1 PKT TP THREE TIMES A WEEK, Fluocinonide 0.05% Cream 1 Appl TP DAILY, Mupirocin Cream 2% 1 Appl TP [Hospital1 ], and Silver Sulfadiazine 1% Cream 1 Appl TP DAILY per prior derm recommendations. . # CK elevation: Possible component of rhabdo. Large blood but only few RBC's in urine would be consistent with this. CKs improved as did creatinine. . # COPD: Continue Atrovent and Advair as above . # PAF: In sinus this admission. Bblocker as above. Continued warfarin with goal INR [3-14]. Was supratherapeutic the day was discharge so warfarin dose was reduced from 3mg to 2mg daily. . # Sleep apnea: Continued home BiPap . # DM II: ISS in house. Discharged on home regimen. . # Seizure: Dilantin as above . Medications on Admission: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Fluocinonide 0.05 % Cream Sig: One (1) Appl Topical DAILY (Daily): apply to arms and lower legs . 3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1) puff Inhalation four times a day. 6. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day): apply to open areas on legs. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3) Capsule PO QHS (once a day (at bedtime)). 9. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical DAILY (Daily). 10. Aluminum-Calcium Packet Sig: One (1) Packet Topical THREE TIMES A WEEK (). 11. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 15. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 16. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 17. Warfarin 3 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 18. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 19. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff Inhalation four times a day as needed for shortness of breath or wheezing. Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Fluocinonide 0.05 % Cream Sig: One (1) Appl Topical DAILY (Daily): apply to arms and lower legs . Disp:50 g Refills:2 3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:60 Disk with Device(s) Refills:2 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1) puff Inhalation four times a day. Disp:1 inhaler Refills:2 6. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day): apply to open areas on legs. Disp:50 g Refills:2 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:2 8. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3) Capsule PO QHS (once a day (at bedtime)). Disp:90 Capsule(s) Refills:2 9. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical DAILY (Daily). Disp:50 g Refills:2 10. Aluminum-Calcium Packet Sig: One (1) Packet Topical THREE TIMES A WEEK (). Disp:10 Packet(s) Refills:2 11. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 14. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:15 Tablet(s) Refills:2 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:60 Capsule(s) Refills:2 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 17. Isosorbide Mononitrate 30 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 18. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 19. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:30 Tablet(s) Refills:2 20. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:20 Tablet(s) Refills:0 21. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 22. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff Inhalation four times a day as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:2 Discharge Disposition: Home With Service Facility: [Hospital6 1952], [Location (un) 86] Discharge Diagnosis: Primary: Pyelonephritis, congestive heart failure exacerbation . Secondary: lymphedema / elephanitiasis, hypertension, diabetes, seizures Discharge Condition: Stable vital signs, on room air, at baseline Discharge Instructions: You were admitted after passing out. You were found to have worsened congestive heart failure and a severe urinary tract infection. We gave your Lasix and breathing medications and your heart failure improved. We treated you with antibiotics for your infection. You will need to continue the antibiotics after you leave the hospital. . Please take your medications as ordered. In particular it is important that you take Bactrim DS 1 pill twice a day for 10 more days for your infection. . Please call your doctor or come to the emergency department if you experience chest pain, palpitations, shortness of breath, bleeding, fevers, or other concerning symptoms. Followup Instructions: MD: Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 8682] Specialty: pcp Date and time: [6-28] at 1:30pm Location: [Location (un) ], [Hospital 172] Medical Group Phone number: [Telephone/Fax (1) 133] [Name6 (MD) 251] [Name8 (MD) ] MD [MD Number(1) 910] Completed by:[2130-6-14]	[ "585.9", "428.0", "590.80", "414.01", "428.41", "728.88", "V58.61", "427.31", "276.2", "327.23", "584.9", "278.01", "457.1", "345.90", "491.21", "403.90", "424.1", "250.00" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	15016, 15091	6999, 10400	324, 330	15272, 15318	4807, 4807	16029, 16388	4071, 4085		12233, 14993		15112, 15251		10426, 12210				15342, 16006					5370, 6976								4100, 4788																										274, 286							358, 3245						4823, 5354											3267, 3839	3855, 4055
22,170	115,214	1377	Discharge summary	report	Admission Date: [2174-12-8] Discharge Date: [2174-12-13] Date of Birth: Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 33 year-old woman who has a long complicated medical history including bilateral breast cancer the first one in [2164] on the right side, which is treated with lumpectomy and radiation. She now has a new cancer on the opposite side. She came in electively for bilateral mastectomy. PAST MEDICAL HISTORY: Breast cancer and minor kidney problems. There aer no other major medical problems. ALLERGIES: Penicillin and Compazine. MEDICATIONS ON ADMISSION: 1. Tylenol. 2. Prn Claritin. HOSPITAL COURSE: On the day of admission she was taken to the Operating Room where she underwent bilateral mastectomies followed by bilateral muscle sparing free TRAM breast reconstruction. Despite the major procedure she had actually a really benign postoperative course. She was in the Intensive Care Unit for a few days undergoing frequent flap checks which went very well and there were no major hospital problems. She was able to ambulate and be discharged by hospital day five without any complications. DISCHARGE MEDICATIONS: 1. Dilaudid prn. 2. Po Keflex. FOLLOW UP: She will be followed up in the office in a few days. I should note that all drains were removed prior to discharge and despite the size of the major procedure she had a remarkably good postoperative course. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8332], M.D. [MD Number(1) 8333] Dictated By:[Last Name (NamePattern4) 8334] MEDQUIST36 D: [2175-1-30] 07:04 T: [2175-1-31] 10:29 JOB#: [Job Number 8335]	[ "174.8", "997.4", "560.1", "E878.6" ]	icd9cm	[ [ [] ] ]	[ "85.7", "85.42" ]	icd9pcs	[ [ [] ] ]									1195, 1229				625, 657	675, 1172																									1241, 1729																								152, 451																	474, 599
32,740	160,320	33262	Discharge summary	report	Admission Date: [2104-11-7] Discharge Date: [2104-11-11] Date of Birth: [2026-4-10] Sex: M Service: MEDICINE Allergies: Zithromax / Erythromycin Base Attending:[First Name3 (LF) 898] Chief Complaint: Respiratory distress, fall Major Surgical or Invasive Procedure: None History of Present Illness: 78-year-old NH resident with COPD on 2L NC, DM, CAD s/p multiple PCI admitted after a mechanical fall. Was well until [10-16] when a RLL infiltrate was noted on CXR. Treated with levofloxacin 500 mg x 7 days as an outpatient without improvement. Admitted to [Hospital1 18] [Date range (1) 17343] for altered mental status and was treated with levofloxacin 750 mg x 10 days (ended [10-27]) for pneumonia and prednisone taper (ended [11-7]) for COPD exacerbation. Reports having had a mechanical fall on the morning of admission when he leaned forward on a folding food table that subsequently collapsed. He denies head trauma, loss of consciousness, or prodromal dizziness, lightheadedness, syncope, sweating, chest pain, palpitations, shortness of breath, or nausea. He denies having sustained any bodily injury. He endorses cough with brown sputum that is unchanged in quality but increased in quantity. He's had diarrhea that he cannot quantify or state when it began. No fever, chills, sweats, weight change, abdominal pain, vomiting, hematochezia, or melena. EMS records reflect episodes of desaturation to 87%on 2L NC but documented recent noncompliance with O2. In the ED, initial VS 97.3 87 153/87 32 84%RA (although also documented as 84%4L on triage notes). CXR showed an unchanged small R pleural effusion and increase in a patchy RLL patchy opacity compared with a study from [10-24]. Given vancomycin 1 g, levofloxacin 750 mg IV, ceftriaxone 1 g, solumedrol 125 mg IV, nebulized bronchodilators. BP 211/112 given SL NTG then SBP 86/50, given 500 cc with improvement in sbp 135 given another 500 cc bolus for a total of 1.5L in the ED. Vital signs prior to transfer T 98.2 HR 113 afib BP 117/52 RR 20-22 O2sat 92%4L NC. Upon arrival in the MICU, the patient is hungry but otherwise without complaints. Past Medical History: 1. COPD on 2LO2 2. Multivessel CAD s/p BMS to the RCA and LCX [4-30], PTCA/BMSx2 to mid-LAD [6-30] 3. DMII 4. PAD s/p L SFA stent 5. Atrial fibrillation 6. Hypertension 7. Hyperlipidemia 8. [Last Name (un) 309] body dementia 9. Duodenal ulcer [8-30] EGD Social History: Currently lives in Stone [Hospital3 ] home. He continues to smoke at least one pack of cigarettes a day (smoked for 60 years). Denies etoh use, h/o IVDU. Family History: Non-contributory. Physical Exam: Vitals - T 97.8 BP 146/83 HR 109 RR 20 02sat 96%1L GENERAL: Well-appearing, resp non-labored HEENT: sclera anicteric dry MM NECK: supple no JVD no C-spine TTP CARDIAC: irreg irreg tachy no m/r/g LUNGS: crackles R base, diminished at L base scattered end-exp wheezes bilat no rhonchi ABDOMEN: soft NTND normoactive BS EXT: warm, dry diminished distal pulses NEURO: awake, alert, converses appropriately, oriented to person, place, month, year, president DERM: bilat ant LE chronic venous stasis changes, <1 cm ulcer on R heel with clean base and granulation tissue Pertinent Results: EKG: [11-7] @ 1138 AFib with RVR 112 bpm borderline LAD QIII nonspecific <[Street Address(2) 77237] depressions not significantly changed from [2104-10-24] . CXR: small r pleural effusion stable since prior RLL patchy opacity increased since prior study cardiac size upper limit normal. . CT Chest w/o contrast: IMPRESSION: 1. Multifocal infiltrates, predominantly in the right lower lobe and mild in the left lower lobe, focal consolidation in the right lower lobe. Findings are compatible with predominantly right lower lobe pneumonia, question aspiration. 2. Mild centrilobular emphysema. 3. Marked coronary artery calcification, with evidence coronary stenting or bypass. 4. Cholelithiasis without acute cholecystitis. . Admission labs: [2104-11-7] 12:04PM WBC-14.6* RBC-5.19 HGB-15.7 HCT-49.5 MCV-95 MCH-30.3 MCHC-31.8 RDW-16.3* PLT COUNT-215 [2104-11-7] 12:04PM NEUTS-84.4* LYMPHS-10.1* MONOS-4.7 EOS-0.5 BASOS-0.3 [2104-11-7] 12:04PM PT-13.2 PTT-20.2* INR(PT)-1.1 [2104-11-7] 12:04PM cTropnT-<0.01 [2104-11-7] 12:04PM CK(CPK)-45 [2104-11-7] 12:04PM GLUCOSE-183* UREA N-38* CREAT-1.0 SODIUM-144 POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-42* ANION GAP-11 [2104-11-7] 12:18PM LACTATE-3.0* [2104-11-7] 02:01PM LACTATE-2.2* [2104-11-7] 02:01PM TYPE-[Last Name (un) ] O2 FLOW-3 PO2-58* PCO2-69* PH-7.35 TOTAL CO2-40* BASE XS-8 INTUBATED-NOT INTUBA COMMENTS-NASAL [Last Name (un) 154] [2104-11-7] 05:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.5 LEUK-TR [2104-11-7] 05:30PM URINE RBC-[12-12]* WBC-[3-27] BACTERIA-OCC YEAST-NONE EPI-0 . Discharge labs: [2104-11-10] 08:00AM BLOOD WBC-10.8 RBC-4.67 Hgb-14.4 Hct-44.5 MCV-95 MCH-30.9 MCHC-32.4 RDW-15.9* Plt Ct-155 [2104-11-9] 08:15AM BLOOD Neuts-79.3* Lymphs-14.6* Monos-4.8 Eos-1.1 Baso-0.3 [2104-11-10] 08:00AM BLOOD Glucose-202* UreaN-24* Creat-0.8 Na-143 K-5.2* Cl-98 HCO3-40* AnGap-10 [2104-11-10] 08:20PM BLOOD K-4.5 [2104-11-10] 08:00AM BLOOD Calcium-9.3 Phos-2.7 Mg-2.3 Brief Hospital Course: 78-year-old NH resident with COPD on 2L NC, DM, CAD s/p multiple PCI admitted after a mechanical fall with radiographic evidence of worsening healthcare associated pneumonia. Hospital course by problem: . #Healthcare associated PNA: On admission, the patient was hemodynamically stable and afebrile with a mild leukocytosis and no oxygen requirement above baseline. His CT scan, however, showed multifocal infiltrates, more prominently in the right lung. Our differential was a resistent organism or persistent aspiration. He was started on IV vancomycin and cefepime empirically as he has failed extensive quinolone therapy and has a macrolide allergy. His sputum culture showed only commensal flora and blood cultures are negative to date. His sputum gram stain did show gram negative rods and we were concerned for pseudomonas or MRSA infection. He should therefore get a 14-day course of cefepime and vancomycin. A PICC line was placed so that the IV antibiotics could be given at his nursing home. He was also given chest physical therapy, producing large amounts of brown-tinged sputum. This should be continued if possible. The patient was admitted on 2L of Oxygen by nasal cannula from rehab. It does not appear that he uses Oxygen normally at home. He can be weaned off of Oxygen as tolerated. He was also evaluated for aspiration. He reports that he sometimes coughs while eating meals. A bed-side swallowing exam was normal. A video swallow study showed trace penetration with thin liquids but no signs of aspiration. He should tuck his chin while drinking thin liquids and take small bites. . # Type II diabetes: He was hypoglycemic at times, down to a fingerstick of 44 one morning and 67 one day before dinner. His home NPH dosing was reduced to 25units before breakfast and dinner, with improvement in his glucose levels. His sliding scale insulin was reduced. . #COPD - He did not have signs of a COPD exacerbation and was continued on his spiriva with nebulizers as needed. While he arrived on 2 liters of Oxygen by nasal cannula, he does not use O2 at home and should be weaned off of this as tolerated. He was not given steroids. He was not interested in quitting smoking at this time. . #Atrial fibrillation - His aspirin dose was increased to 325mg daily as he is not a candidate for warfarin given his frequent falls. His beta blocker was increased to give better rate control, to 75mg twice a day. This can be increased further as an outpatient as tolerated. . #Dementia: The patient was continued on his home doses of donezepil, paroxetine and mirtazapine. He often sun-downed and needed redirection, but antipsychotics or restraints were not needed. . #Code status: The patient was DNR with possible intubation, as documented in his paperwork. His brother, [Name (NI) ] [Name (NI) 77238], [Telephone/Fax (1) 77239], is his health care proxy. Medications on Admission: Aspirin 81 mg PO DAILY Digoxin 125 mcg PO DAILY Furosemide 20 mg PO DAILY Multivitamin PO DAILY Paroxetine HCl 20 mg PO DAILY Clopidogrel 75 mg PO DAILY Thiamine HCl 100 mg PO DAILY Donepezil 10 mg PO once a day. Humulin N 30 units twice a day Novolog sliding scale Lisinopril 5 mg PO once a day Spiriva (1) capsule Inhalation once a day Metoprolol Tartrate 75 mg PO BID Divalproex SR 1250 mg PO at bedtime Mirtazapine 7.5 mg PO HS Simvastatin 40 mg PO at bedtime Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Nitroglycerin 0.3 mg Tablet Sublingual PRN (as needed) as needed for chest pain. Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. Divalproex 250 mg Tablet Sustained Release 24 hr Sig: Five (5) Tablet Sustained Release 24 hr PO HS (at bedtime). 14. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulization Inhalation Q6H (every 6 hours) as needed for sob/wheezing. 16. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual PRN as needed for chest pain. 17. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Twenty Five (25) units Subcutaneous twice a day: Please give with breakfast and dinner. 18. Insulin Aspart 100 unit/mL Cartridge Sig: see sliding dose below Subcutaneous four times a day: before meals, before bedtime: For blood glucose 151-200: 2 units, for 201-250: 4 units, 251-300: 6 units, 301-350: 8 units, 351-400: 10 units. 19. Cefepime 2 gram Recon Soln Sig: Two (2) grams Intravenous every twelve (12) hours for 9 days. 20. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg Intravenous every twelve (12) hours for 9 days. 21. Miralax 17 gram/dose Powder Sig: One (1) PO three times a day as needed for constipation. 22. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 23. Senna 8.6 mg Tablet Sig: One (1) Tablet PO three times a day as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital6 4657] - [Location 1268] Discharge Diagnosis: Primary diagnosis: Hospital acquired pneumonia . Secondary diagnoses: Chronic Obstructive Pulmonary Disease Type II diabetes mellitus Coronary artery disease Dementia Discharge Condition: Stable. Respiratory status improved to baseline. Discharge Instructions: You were admitted because you fell and were found to have a continued pneumonia in your lungs. Your pneumonia was treated with a different antibiotic than before, and you seem to be doing better. You are now ready to go back to the Stone [Hospital 77240] home. . - Please continue to take your intravenous antibiotics (vancomycin and cefepime) for nine more days. These meds will be given to you. - Please take a higher dose of aspirin (325mg instead of 81mg) because you have atrial fibrillation but are not a candidate for coumadin. - We increased your metoprolol to 100mg twice a day to better treat your high blood pressures. - We reduced your long-acting insulin because you were having low glucose levels. You should take 25 units of NPH with breakfast and dinner. Your sliding scale was not changed. - Please take Colace twice a day and Senna and Miralax as needed to prevent constipation. . Please take the rest of your medications as you were prior to admission. . Please call your doctor or come back to the hospital if you have difficulty breathing, fever, chills, chest pain or other worrisome symptoms. Followup Instructions: Podiatrist: [Doctor First Name ] [Doctor Last Name ], DPM Phone:[Telephone/Fax (1) 543] Date/Time:[2104-11-20] 9:40 . Patient will be seen by the doctors [First Name (Titles) ] [Last Name (Titles) ] [Hospital3 ] Home Completed by:[2104-11-11]	[ "294.10", "331.82", "294.8", "443.9", "250.80", "492.8", "272.4", "459.81", "V45.82", "486", "293.0", "707.14", "427.31", "518.81", "276.2", "414.01", "401.9" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	11109, 11178	5411, 8315	317, 324	11389, 11440	3296, 4033	12613, 12890	2677, 2696		8968, 11086		11199, 11199		8341, 8945				11464, 12590					4993, 5388								2711, 3277			11269, 11368																							251, 279							352, 2191						4049, 4977	11218, 11248										2213, 2485	2501, 2661
2,177	100,402	30867	Discharge summary	report	Admission Date: [2114-3-27] Discharge Date: [2114-3-29] Date of Birth: [2091-12-16] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 330] Chief Complaint: Altered mental status, tylenol overdose Major Surgical or Invasive Procedure: None History of Present Illness: 22 F with history of ETOH abuse, IVDU of heroin, cocaine, and unknown street drugs, bipolar disorder, transferred from [Location (un) ] hospital with tylenol overdose. (The patient was not able to give much of this history because of drowsiness, so much of this history was given by her mother.) She took 15 tylenol pm last night, sometime between evening and midnight. She usually takes 4 tylenol PM every night to help her sleep, but last night she couldn't sleep, so she took 15 tylenol PM. According to her mother, she took klonepin yesterday as well (her daughter had told her she had taken it), but she doesn't know the amount. Patient does not take any medications on home regimen. . According to the patient and her mother, the patient was not taking 15 tylenol PM as a suicide attempt. The patient states that she did not wish to hurt herself, but took the pills because she couldn't sleep or rest. She said she usually takes Tylenol PM and thought that taking more pills would increase the effect of helping her sleep. She reports abdominal pain, aching in her muscles "all over", sleepiness, "feel like I have the flu". . Her mother had actually taken her to [Hospital3 ] hospital 2 days ago, on Sunday afternoon at 2:30 pm, because she was "acting funny", sitting on the floor, not answering questions, looking disheveled, acting belligerent and temperamental, which is very uncharacteristic for the patient per mother. [Name (NI) ] mother states that her daughter "can be really difficult, but is the type who will never leave the house without a perfectly matched outfit and makeup". Her boyfriend and mother assumed that she was "strung out on drugs". She was taken by ambulance to [Hospital3 ] hospital on Sunday at 2:30 pm and returned home by 7:30 pm from the hospital. Her mother does not know what transpired during her ED visit on Sunday. She was not with her daughter during that hospital visit, but after she returned from the hospital, her daughter seemed more back to her normal self per mother. . Late on Monday night, mother called ambulance since patient seemed obtunded and ill. At OSH, she had vomiting, dry heaves, nausea, restlessness; she was given zofran 8 mg IV. EMS found BG 32, was given D25; BG 162 on arrival to OSH; BG decreased to 70 and was given D50 on floor. AST >10,000, ALT >5,000, Cr 2.13, TBili 4.8, DBili 2.9, Alk phos 127. ABG: 7.32 / 24 / 121 / 12 on 2L nc. She had an abdominal US and was found to have liver and renal failure. She received NAC 7g load plus 2.5g by 4 am Tuesday before being transferred to [Hospital1 18] ED. . In the [Hospital1 18] ED, vitals were T 97.7, HR 132, 105/47, RR 26, 100% 3L nc on admission. Hepatology was consulted and recommended 17 mg/kg/hr IV NAC infusion. Toxicology was also consulted. INR 14.1, liver enzymes pending, acetaminophen level was negative. Received 2250 ml NS in ED, received [2106] ml NS at OSH. She was transferred to MICU Green. . In subsequent information obtained from the patient's mother in private: the patient has a history of bipolar disorder, she has tried to slash her wrists in past suicide attempts, she refuses all treatment and is noncompliant with medical recommendations and medications, she has signed AMA out of a psychiatry hospital, she has boyfriend with Hepatitis C, and she takes heroin or any IV drugs whenever she has access. . REVIEW OF SYSTEMS: Patient cannot answer questions due to obtundation. +abdominal pain. +generalized pain which does not localize. No fever, no chills, no vomiting, no diarrhea, no blood per rectum. Past Medical History: - ETOH abuse: 60 beers + 1 bottle rum + 1 bottle jagermeister per week - Hepatitis C - Chronic tylenol PM use: 4 pills per night for at least the past few years - IV drug use: heroin, cocaine, possibly other drugs - Illicit drug use: unprescribed klonepin, percocet - Bipolar disorder: refuses medical treatment and signed out AMA from psychiatric [Hospital1 ] - Previous suicide attempts: slashing wrists Social History: ETOH: Per mother, she drinks 60 beers ("at least two 30-packs"), a bottle of rum, and some jagermeister per week. Her mother estimates that the amount is more than that, since that is what she witnesses herself, but she does not see what her daughter drinks when she is out of the house. She drinks a beer every morning before going to work, and she often skips work because she is inebriated. . IV drugs: Per mother and patient, she has used heroin and cocaine in the past. . Other drugs: She has a history of using percocet and klonopin for non-medical reasons and without a prescription. Her mother reports that it is very easy to gain access to these drugs in her neighborhood. . ADLs: She works as a roofer for her father. She shows up to work approximately 10-15 days out of each month because of her ETOH and drug use, but she is able to keep her job because she works for her father. She lives at home with her mother, who works nights. Her mother states that "it's impossible to keep track of her" and feels that since she is an adult at 22, she can lead her own life. She has a boyfriend who has hepatitis C. She has not been tested for HIV or hepatitis. Family History: No liver disease in first degree relative. [Name (NI) ] family member or frequenter to the house currently ill. Physical Exam: VS: 97.7 / HR 125-135 / 107/47 / 20 / 98% 4L nc (85% on RA) GEN: Drowsy, irritable, restless, cannot answer questions. Falls asleep in the middle of history-taking and exam. Can move around on the bed without being limited by pain. Tachypneic. HEENT: Subtle ecchymoses over eyelids bilaterally, no ecchymoses behind ears. PERRL, no scleral icterus, cannot perform EOM exam due to lack of concentration, cannot assess nystagmus. Nasal turbinates clear with normal nasal septum. Dry mucous membranes. NECK: No LAD, soft, supple. No carotid bruits heard. No thyroid masses or thyromegaly. CV: Regular, tachy. [1-2] flow SEM heard best at apex, no rub or gallop, clear S1 and S2 with no S3 or S4 LUNGS: Quiet rhonchi and bibasilar rales, no wheezing. ABD: Soft, normoactive BS, nondistended. Diffusely tender with mild palpation, especially in right quadrant and epigastrium, no rebound, moderate guarding. No bruits heard. BACK: Mild costovertebral tenderness. Ext: No track marks on arms. Asterixis present bilaterally. No cyanosis, no clubbing, no edema. Neuro: Oriented to person, place, year. CN 2-12 intact as tested. 5 motor in arms and legs. 2+ reflexes in triceps, biceps, patellar, Achilles. Toes downgoing. Did not assess gait. Pertinent Results: [2114-3-27] 08:37PM TYPE-[Last Name (un) ] TEMP-36.9 PO2-32* PCO2-31* PH-7.30* TOTAL CO2-16* BASE XS--10 INTUBATED-NOT INTUBA [2114-3-27] 08:37PM LACTATE-5.2* [2114-3-27] 08:37PM freeCa-0.88* [2114-3-27] 08:17PM GLUCOSE-120* UREA N-30* CREAT-2.6* SODIUM-139 POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-15* ANION GAP-26* [2114-3-27] 08:17PM CALCIUM-8.0* PHOSPHATE-5.1* MAGNESIUM-2.4 [2114-3-27] 08:17PM URINE HOURS-RANDOM [2114-3-27] 08:17PM URINE UCG-NEGATIVE [2114-3-27] 08:17PM WBC-12.3* RBC-2.08* HGB-6.9* HCT-19.6* MCV-94 MCH-33.3* MCHC-35.4* RDW-13.5 [2114-3-27] 08:17PM PLT COUNT-108* [2114-3-27] 08:17PM PT-42.5* PTT-57.0* INR(PT)-4.8* [2114-3-27] 12:36PM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.025 [2114-3-27] 12:36PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-TR [2114-3-27] 12:36PM URINE RBC-0-2 WBC-0 BACTERIA-0 YEAST-MOD EPI-0 [2114-3-27] 12:33PM LACTATE-6.8* [2114-3-27] 12:28PM GLUCOSE-134* UREA N-32* CREAT-2.5* SODIUM-136 POTASSIUM-5.3* CHLORIDE-99 TOTAL CO2-15* ANION GAP-27* [2114-3-27] 12:28PM LD(LDH)-8210* DIR BILI-2.5* [2114-3-27] 12:28PM CALCIUM-8.2* PHOSPHATE-5.4* MAGNESIUM-2.8* [2114-3-27] 12:28PM HAPTOGLOB-37 [2114-3-27] 12:28PM WBC-19.0* RBC-2.62* HGB-8.5* HCT-24.8* MCV-95 MCH-32.5* MCHC-34.3 RDW-13.5 [2114-3-27] 12:28PM PLT COUNT-118* [2114-3-27] 12:28PM PT-31.6* PTT-46.8* INR(PT)-3.4* [2114-3-27] 12:28PM PT-31.6* PTT-46.8* INR(PT)-3.4* [2114-3-27] 12:15PM AMMONIA-69* [2114-3-27] 12:09PM TOT PROT-5.3* IRON-224* CHOLEST-88 [2114-3-27] 12:09PM calTIBC-229* FERRITIN-GREATER TH TRF-176* [2114-3-27] 12:09PM TRIGLYCER-89 HDL CHOL-50 CHOL/HDL-1.8 LDL(CALC)-20 [2114-3-27] 12:09PM OSMOLAL-308 [2114-3-27] 12:09PM TSH-0.40 [2114-3-27] 12:09PM HBsAg-NEGATIVE HBs Ab-POSITIVE HBc Ab-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [2114-3-27] 12:09PM Smooth-NEGATIVE [2114-3-27] 12:09PM [Doctor First Name ]-NEGATIVE [2114-3-27] 12:09PM TSH-0.40 [2114-3-27] 12:09PM HBsAg-NEGATIVE HBs Ab-POSITIVE HBc Ab-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [2114-3-27] 12:09PM Smooth-NEGATIVE [2114-3-27] 12:09PM [Doctor First Name ]-NEGATIVE [2114-3-27] 12:09PM AFP-<1.0 [2114-3-27] 12:09PM HIV Ab-NEGATIVE F [2114-3-27] 12:09PM HCV Ab-POSITIVE [2114-3-27] 11:38AM TYPE-ART TEMP-36.3 PO2-120* PCO2-29* PH-7.33* TOTAL CO2-16* BASE XS--9 INTUBATED-NOT INTUBA [2114-3-27] 11:38AM LACTATE-6.7* [2114-3-27] 11:38AM O2 SAT-97 [2114-3-27] 11:38AM freeCa-0.85* [2114-3-27] 10:14AM TYPE-ART TEMP-36.1 RATES-/24 O2 FLOW-2 PO2-51* PCO2-31* PH-7.30* TOTAL CO2-16* BASE XS--9 INTUBATED-NOT INTUBA COMMENTS-NASAL [Last Name (un) 154] [2114-3-27] 10:14AM LACTATE-8.3* [2114-3-27] 09:07AM PO2-78* PCO2-34* PH-7.30* TOTAL CO2-17* BASE XS--8 [2114-3-27] 09:07AM GLUCOSE-172* LACTATE-9.5* NA+-133* K+-5.2 CL--100 [2114-3-27] 08:45AM GLUCOSE-180* UREA N-34* CREAT-2.5* SODIUM-133 POTASSIUM-5.2* CHLORIDE-93* TOTAL CO2-12* ANION GAP-33* [2114-3-27] 08:45AM estGFR-Using this [2114-3-27] 08:45AM ALT(SGPT)-9260* AST(SGOT)-[Numeric Identifier 29620]* ALK PHOS-122* AMYLASE-108* TOT BILI-4.2* [2114-3-27] 08:45AM LIPASE-186* [2114-3-27] 08:45AM CALCIUM-8.7 PHOSPHATE-5.8* MAGNESIUM-3.0* [2114-3-27] 08:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2114-3-27] 08:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2114-3-27] 08:45AM URINE HOURS-RANDOM UREA N-263 CREAT-92 SODIUM-17 [2114-3-27] 08:45AM URINE UCG-NEGATIVE OSMOLAL-396 [2114-3-27] 08:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG [2114-3-27] 08:45AM WBC-23.1* RBC-3.37* HGB-11.2* HCT-32.0* MCV-95 MCH-33.3* MCHC-35.0 RDW-13.3 [2114-3-27] 08:45AM NEUTS-91* BANDS-0 LYMPHS-1* MONOS-8 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2114-3-27] 08:45AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2114-3-27] 08:45AM PLT SMR-LOW PLT COUNT-148* [2114-3-27] 08:45AM PT-102.0* PTT-53.7* INR(PT)-14.2* [2114-3-27] 08:45AM URINE COLOR-Amber APPEAR-Hazy SP [Last Name (un) 155]-1.020 [2114-3-27] 08:45AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2114-3-27] 08:45AM URINE RBC-[1-29]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [2114-3-27] 08:45AM URINE AMORPH-FEW . EKG: Sinus tachycardia Low QRS voltage - clinical correlation is suggested Since previous tracing of [2114-3-28], axis less rightward Intervals Axes Rate PR QRS QT/QTc P QRS T 123 148 90 284/357.28 47 64 29 . CXR [2114-3-29]: The ET tube tip is 6 cm above the carina. The left internal jugular line tip is terminating in the low SVC. There is no pneumothorax or apical hematoma identified. The NG tube tip terminates in the stomach. There is no significant change in bilateral perihilar and lower lobe consolidations. Small bilateral pleural effusion cannot be excluded though there is no evidence of large pleural fluid. . CT Head/Chest/Abd/Pelv [2114-3-29]: NON-CONTRAST HEAD CT: There is diffuse edema of the brain parenchyma with loss of [Doctor Last Name 352]- white matter differentiation and obliteration of the ventricular system. There is also obliteration of all basilar cisterns. Obliteration of the pre- mesencephalic space suggests bilateral uncal herniation. Complete obliteration of ambient cistern suggests transtentorial herniation. There is also complete obliteration of CSF space at foramen magnum suggesting tonsillar herniation. No focal mass lesion is seen. No major or minor vascular territorial infarct is detected. No shift of normal midline structure is seen. The surrounding bony and soft tissue structures are unremarkable with no evidence of fracture. The maxillary sinuses are normal.The ethmoid sinuses , frontal sinuses and Sphenoid sinuses demonstrate mucosal thickening. IMPRESSION: Severe diffuse brain edema with obliteration of all CSF spaces with uncal, downward transtentorial and tonsillar herniation. . CT chest [2114-3-29]: IMPRESSION: 1. No evidence of acute bleeding is seen within the chest, abdomen or pelvis to explain the patient unresponsiveness. 2. Small bilateral pleural effusions, more prominent on the left side. 3. Bilateral ground-glass opacities and consolidations, centered on the bronchovascular bundle, which may suggest aspiration pneumonitis. 4. Anasarca and ascites. . TTE [2114-3-27]: Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). 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 appear structurally normal with good leaflet excursion. There is no valvular aortic stenosis. The increased transaortic gradient is likely related to high cardiac output. No aortic regurgitation is seen. There is no mitral valve prolapse. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Hyperdynamic left ventricular function. Resting tachycardia. No obvious structural valvular disease but evaluation limited due to marked tachycardia. . Abdomen US [2114-3-27]: IMPRESSION: 1. Normal-appearing liver without focal lesion identified. 2. Diffuse bilateral renal cortical echogenicity consistent with diffuse parenchymal disease. 3. Gallbladder wall edema without evidence of acute cholecystitis which may be seen with liver disease and hypoalbuminemia. Brief Hospital Course: 22 F with history of heavy ETOH abuse, HCV, IVDU of heroin, cocaine, and unknown street drugs, bipolar disorder, transferred from [Hospital3 ] Hospital and admitted to MICU with tylenol overdose, renal failure, and altered mental status, improved for the first 3 days, then evolved to brain death due to brain herniation. . # Acute fulminant liver failure: Patient has a history of heavy ETOH abuse, HCV, with fulminant liver failure precipitated by tylenol overdose. MELD was 50 with a 98% predicted mortality on admission. Acetaminophen level was negative, AST [Numeric Identifier 29620], ALT 9260, INR 14.1, TB 4.2 on admission. She had been loaded with N-acetylcysteine IV infusion at [Location (un) 21541] Hospital, and then was transferred to the [Hospital1 18] ED. Hepatology consult and Toxicology consult were called and gave initial recommendations on NAC dosing. . In the MICU, 17 mg/kg/hr NAC per hour was started at the time of admission. Her initial workup covered viruses, toxins, drugs, autoimmune, shock liver, hemochromatosis, liver cancer, and sepsis as an alternative impetus for liver failure. She was HBV immune (HBsAb positive), HCV Ab positive, HIV negative, CMV negative, Monospot negative, [Doctor First Name ] negative, AFP negative, TIBC low (229), ferritin >[2106] (inflammation). Urine toxin screen was positive for cocaine. Serum toxin screen was negative (included opiates, cocaine, benzodiazepines). TTE was ordered to assess possibility of shock liver, in addition to assessment of flow murmur on exam; TTE showed hyperdynamic LV systolic function with EF > 75%. EKG showed sinus tachycardia. Patient was guaiac positive with brown stool in the vault. Free calcium was 0.85 and was aggressively repleted. Normal serum glucose was maintained with D50 and slow D5W infusion. . Hepatology consult assessed that the patient would not be a liver transplant candidate, due to her continued heavy ETOH abuse, continued illicit IV drug use, nonprescribed heavy klonepin and percocet use, and previous consistent refusal of medical treatment and recommendations (history of signing out against medical advice from hospitals). This plan was discussed with her mother, father, aunt, and family, who understood and agreed. . MICU and hepatology team discussed intracranial pressure monitoring using a bolt, and it was agreed that no bolt would be placed, as patient was not a liver transplant candidate. Neurologic exam was performed every hour. Her neurologic exam on admission showed pupils constricting briskly 4 to 3 mm on the right and 4 to 3 mm on the left, and she was drowsy but oriented to person, place, year. She required a high dose of propofol to maintain proper sedation. On [3-28], when sedation was turned down to test mental status, she withdrew appropriately to painful stimuli, and pupils were briskly reactive. . The patient had an episode of vomiting and for concern of airway protection and aspiration, she was sedated, intubated, and LIJ central line and arterial line was placed [3-28]. She was noted to have diffuse ecchymoses over the eyelids, behind her ears, and on bilateral abdomen, thought to be secondary to coagulopathy. This elicited concern for a retroperitoneal bleed, but since patient was not a candidate for surgical repair at the time, and since the patient's clinical status was very tenuous and she was not safe to leave the ICU, CT was not performed at this time. . On [3-29] AM, sedation was turned down to test mental status, and she withdrew more slowly to painful stimuli, and pupils were still equally reactive. Ecchymoses had expanded anteriorly over abdomen, but abdomen was soft with bowel sounds and hematocrit was maintained > 21 with pRBC transfusions. On [3-29] AM, with no change in medications or sedation for the past hour, she was noted to have sudden spike of BP >200/>110 and HR 150s. She was given ativan 1 mg IV and labetalol 10 IV and her BP immediately returned to 110/60 and HR 70s. Neurologic exam was performed and vitals were measured every hour with no change. . On [3-29] early afternoon, neurologic exam suddenly showed right pupil 5 mm nonreactive and left pupil slow to react 4 to 3 mm. Sedation was turned off and patient no longer reacted to painful stimuli. Mannitol and CT head, chest, abdomen, pelvis were ordered. Within minutes, the patient's pupils became fixed and dilated. CT head showed uncal, transtentorial, and tonsillar herniation. Neurology reported brain death on [3-29]. Organ bank assessed patient as candidate for heart donation only due to hepatitis C. The patient was subsequently given further support for cardiac care for organ donation from [3-29] to [3-30]. . # Coagulopathy/bleeding: Since admission, her hematocrit continued to decrease and her INR continued to increase. She received a total of 4 pRBC, 12 FFP, and 1 cryoprecipitate transfusions over 3 days before death. INR was initially 14.1 and was maintained with a goal INR < 4.0; cryoprecipitate was given for fibrinogen < 100; RBC transfusion was given for hematocrit < 21 or for an acute drop. . # Respiratory insufficiency: The patient was hyperventilating with large tidal volumes. She was intubated and on AC after an episode of vomiting, for airway protection. CXR showed bilateral basilar infiltrates concerning for early acute lung injury versus aspiration, and patient was started on levofloxacin to cover for possible aspiration pneumonia. . # ETOH/opiate withdrawal: She was on propofol gtt which controlled withdrawal well. On [3-29] AM, she had one episode of BP 200/110, HR 150s. She was given ativan 1 mg IV and labetalol 10 IV with immediate resolution. . # Renal failure: She received several boluses of NS IVF for prerenal azotemia and Cr 2.5 on admission with no Cr baseline. Her renal function worsened and renal was consulted on [3-28]. Urine output was sufficient, and she did not require HD or CVVH. She was placed on a phosphate binder. It was possible that her renal failure occurred in conjunction with liver failure and/or was associated with cocaine-induced vasoconstriction. . # Hematemesis: Patient had small coffee ground gastric fluid and orogastric tube was placed to low suction. She was placed on pantoprazole IV BID. . # Leukocytosis: WBC 23.1 on admission resolved to 6.3 after one day. Antibiotics were started on [3-28] due to CXR infiltrates. Blood cultures on [3-27] showed positive gram stain, and on [3-31] and [4-2] grew out Corynebacterium species and Fusobacterium nucleatum, beta lactamase negative. Surveillance blood cultures on [3-28] and [3-29] showed no growth or were still pending (no growth yet) by [4-3]. Sputum cultures on [3-28] grew out Streptococcus pneumoniae and MSSA on [4-2], both sensitive to levofloxacin. Urine culture showed 1000 organisms of gram positive organism, likely staphylococcus. . # Hypoglycemia: Patient had one episode of fingerstick glucose 32, and was given D50. D5W infusion was continued with subsequent normal fingerstick glucose readings, which were checked every hour. . # Prophylaxis: She was placed on pneumoboots with no subcutaneous heparin. She was given PPI IV BID for hematemesis. . # Code: Her code was full until her death on [3-29]. Medications on Admission: Tylenol PM 4 pills per night . ALLERGIES: PCN Discharge Medications: Patient expired on [2114-3-29]. Discharge Disposition: Expired Discharge Diagnosis: Patient expired on [2114-3-29]. Discharge Condition: Patient expired on [2114-3-29]. Discharge Instructions: Patient expired on [2114-3-29]. Followup Instructions: Patient expired on [2114-3-29]. Completed by:[2114-4-10]	[ "348.8", "303.91", "E980.0", "459.0", "584.9", "518.81", "348.4", "285.1", "458.29", "572.2", "570", "296.80", "251.2", "965.4", "305.91", "291.81", "286.9" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.04", "96.71", "99.07", "99.04", "99.06" ]	icd9pcs	[ [ [] ] ]	22507, 22516	15033, 22351	312, 318	22595, 22632	6955, 12370	22716, 22782	5562, 5679		22447, 22484		22537, 22574		22377, 22424				22656, 22693													5694, 6936																					3750, 3931					233, 274							346, 3731					12379, 15010												3953, 4364	4380, 5546
3,100	152,037	53793	Discharge summary	report	Admission Date: [2120-5-15] Discharge Date: [2120-5-20] Date of Birth: [2066-10-13] Sex: F Service: MEDICINE Allergies: Ace Inhibitors / Lisinopril Attending:[First Name3 (LF) 2745] Chief Complaint: Hypotension, lethargy Major Surgical or Invasive Procedure: mechanical ventilation History of Present Illness: 53 y.o. spanish speaking female with a history of panhypopituitarism, obstructive sleep apnea, pulmonary artery, obesity-hypoventilation, and diastolic heart failure who presented from home with hypotension and lethargy. History obtained from medical records as pt intubated and sedated. Per notes, she came in with HA and lethargy initially, but was found to be hypotensive and febrile and eventually developed hypercarbic respiratory distress requiring intubation and transfer to the unit. Pt has had multiple hospitalizations, most recently [Date range (1) ] ([1-5] prior to that), for hypercarbic respiratory failure complicated by hypotension, often in the setting of fever without definite source of infection. Recently admit for hypercarbic respiratory failure felt to be d/t progression of obstructive sleep apnea and hypoventilation syndrome. Also was hypotensive transiently, felt to be d/t hypoadrenalism, volume depletion, and propofol during intubation. Also had E.coli UTI resistent to cipro and was treated with CTX. In the ED initial vitals were 100.7, 47/11, 22, 99% on 2L. She was given fluids and solumedrol 125mg IV x 1 and BP increased to 104/70. CXR with concern for possible infiltrate and vancomycin 1gm IV, CTX 1mg IV, and azithromycin 500mg PO x 1 given. Cr elevated from baseline of 1.4 to 3.0. UA positive. Lactate 1.0. In setting of hypotension and suspected infection, concern was for early sepsis. Trop 0.01. BP trended down again to SBP 80??????s and she was given 10mg IV decadron and central line placed and BP responded. She had not been written for BIPAP and by change of shift in a.m. appeared more lethargic and more difficult to arouse. BIPAP ordered and gas after one hour was 7.2/80/86. She remained lethargic, pulling at lines and BIPAP, and concern was for airway protection, and she was intubated (propofol, succinate given). CT head negative. Past Medical History: - Obstructive Sleep Apnea on home BiPap, 16/14 - Obesity Hypoventilation - Multiple admissions for hypercarbic respiratory failure; PFT's consistent with a restrictive defect - PFTs: FVC 39%, FEV1 37%, FEV1/FVC 96%, TLC 59%, DLCO reduced - ASD with right-left shunt (12% shunt fraction documented in nuclear study from [2116-3-30]) - Pulmonary artery hypertension: Echo in [10/2118] demonstrated a TR gradient of 33mmHg ?????? followed by [Location (un) 4507] - Hypertension - Pan-hypopituitarism with partially empty sella on desmopressin, levothyroxine, prednisone ?????? followed by Dr. [Last Name (STitle) ] at [Numeric Identifier 110402] - Diastolic CHF with dilated RA/LA on previous echo - Angioedema (unclear history, possibly related to ACE-I) Social History: Occupation: Drugs: None Tobacco: History Alcohol: None Other: Lives with daughter and 3 grandchildren [Location (un) 6409]. Originally from [Male First Name (un) 1056]. Goes to [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Program Family History: NC Physical Exam: VS: 96.8 148/83 70 100% on 18/5/0.6 Gen: Intubated, arousable HEENT: PERRL, ET tube in place Cardiac: RRR, III/VI SEM best heard RUSB Lungs: Mechanical BS, decreased BS on left, no crackles Abd: soft, NTND, +BS, obese, no scars Ext: no edema Peripheral Vascular: (Right radial pulse: present), (Left radial pulse: present), (Right DP pulse: 2+), (Left DP pulse: 2+) Skin: No rash, no lesions Neurologic: Intubated, sedated but arousable Pertinent Results: [2120-5-14] 10:00PM BLOOD Plt Ct-221 [2120-5-14] 10:00PM BLOOD Glucose-110* UreaN-36* Creat-3.0# Na-142 K-4.8 Cl-99 HCO3-33 AnGap-15 [2120-5-14] 10:00PM BLOOD LD(LDH)-239 CK(CPK)-76 [2120-5-14] 10:00PM BLOOD TSH-<0.02* [2120-5-19] 05:50AM BLOOD TSH-<0.02* [2120-5-16] 02:07AM BLOOD T4-10.8 [2120-5-19] 05:50AM BLOOD T4-7.8 [2120-5-15] 11:17AM BLOOD Type-ART PEEP-8 FiO2-30 pO2-86 pCO2-80* pH-7.19* calTCO2-32* Base XS-0 Intubat-NOT INTUBA Vent-SPONTANEOU CT abd/pelvis w/o contrast [2120-5-15]: CT OF THE ABDOMEN WITHOUT IV CONTRAST: The lung bases demonstrate subsegmental atelectasis. Cardiomegaly. No evidence of pleural or pericardial effusion. The liver is diffusely hypodense consistent with fatty infiltration. The gallbladder, spleen, pancreas, adrenal glands, and kidneys are within normal limits allowing for the lack of IV contrast. There is no mesenteric or retroperitoneal lymphadenopathy. The intra-abdominal loops of small and large bowel are unremarkable. No secondary signs of bowel ischemia are seen. A normal appendix is seen. Small fat-containing umbilical hernia. There is no free air or free fluid within the abdomen. Dependent fluid in the soft tissues overlying the posterior spine. CT OF THE PELVIS WITHOUT IV CONTRAST: The bladder, distal ureters, rectum, and sigmoid are unremarkable. There is no free fluid within the pelvis. No pelvic or inguinal lymphadenopathy is seen. [Month/Day/Year ] WINDOWS: No suspicious lytic or sclerotic lesions are identified. Degenerative changes of the lumbar spine. Short pedicles throughout. Lumbar spine canal stenosis is present at the L3-4 and L4-5 levels. IMPRESSION: 1. No CT findings to explain patient's symptoms. 2. Fatty liver. 3. Spinal canal stenosis, incompletely imaged, an MR study may be performed for further characterization, if warranted by the nature of the patient's back pain. Please note that the study is limited due to lack of IV contrast. CT head w/o IV Contrats [2120-5-15]: IMPRESSION: Limited study without evidence of acute intracranial process. Brief Hospital Course: The patient is a 53 y.o.f. with panhypotituitarism, OSA, obesity hypoventilation, pulmonary HTN, and diastolic heart failure who p/w HA and found to have hypotension and fever and intubated for hypercarbic respiratory failure and with UTI by UA # Hypercarbic respiratory distress ?????? The precipitant was likely not being on regular BIPAP overnight. The patient was initially intubated in the ED for hypercarbia and somnolence. She was put initially on AC, and then switched to pressure support. She initially was placed on high pressure, and eventually was weaned down and sedation was stopped. She was extubated on [5-16]. She did well during the rest of her [Hospital Unit Name 153] stay. She will need overnight BiPap at her home settings. She also uses home O2, and should be continued on 2L but keeping her O2 sats btwn 92-94%. # Hypotension ?????? Initially the patient was hypotensive thought to be due to a UTI. She was given IVFs in the ED, with improvement in her BP. She never required pressors. We continued her on ceftriaxone since in the past she has had e.coli resistant to ciprofloxacin. Her blood pressure improved, and she was eventually restarted on her anti-hypertensive medications for high BP prior to being sent out of the [Hospital Unit Name 153]. Urine cultures are no growth. # Panhypopituitarism ?????? The patient's total T4 is in normal range. The patient is on levothyroxine, steroids, and desmopressin. She was initially put on stress dose steroids which were quickly tapered down as the patient's respiratory status improved. # Acute Kidney Injury ?????? Baseline creatinine 1.0, with no known kidney disease. The likely etiology likely prerenal in setting of hypotension. Her acute renal failure resolved. # Cardiac ISCHEMIA ?????? No signs or symptoms of ischemia PUMP ?????? EF in past normal. Has diastolic dysfunction. Control HR and BP to prevent further pulmonary edema. RHYTHM ?????? NSR On day of discharge, the patient was breathing comfortably, ambulating well and at baseline respiratory status per her daughter. Medications on Admission: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Valsartan 80 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). Disp:30 Tablet(s) Refills:2 7. Valsartan 40 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). Disp:30 Tablet(s) Refills:2 8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation every 4-6 hours as needed for wheezing. Disp:30 nebs Refills:2 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 11. Desmopressin 0.1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 12. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 13. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days. Disp:6 Tablet(s) Refills:0 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 16. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Valsartan 80 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). Disp:30 Tablet(s) Refills:2 7. Valsartan 40 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). Disp:30 Tablet(s) Refills:2 8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation every 4-6 hours as needed for wheezing. Disp:30 nebs Refills:2 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 11. Desmopressin 0.1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 12. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 13. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days. Disp:6 Tablet(s) Refills:0 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 16. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: Americare Discharge Diagnosis: Acute on chronic respiratory failure Obstructive sleep apnea Obesity hypoventilation syndrome Panhypopituitarism Morbid obesity Hypootension - resolved Acute renal failure - resolved Urinary tract infection Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: Provider: [Name10 (NameIs) ] DENSITY TESTING Phone:[Telephone/Fax (1) 4586] Date/Time:[2120-5-29] 10:30 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2164], MD Phone:[Telephone/Fax (1) 1803] Date/Time:[2120-5-29] 11:30 Patient to schedule f/u with PCP [Last Name (NamePattern4) ] 2weeks.	[ "416.8", "278.01", "518.84", "253.2", "428.32", "599.0", "287.5", "041.4", "V46.2", "V58.65", "327.23", "276.0", "428.0", "584.9", "458.9", "305.1" ]	icd9cm	[ [ [] ] ]	[ "96.04", "38.93", "96.71" ]	icd9pcs	[ [ [] ] ]	11564, 11604	6005, 8102	311, 335	11856, 11865	3891, 5982	12014, 12358	3408, 3412		9846, 11541		11625, 11835		8128, 9823				11889, 11991													3427, 3872																										250, 273							363, 2279																	2301, 3077	3093, 3392
80,844	171,476	35402	Discharge summary	report	Admission Date: [2167-4-13] Discharge Date: [2167-4-22] Date of Birth: [2092-10-2] Sex: M Service: MEDICINE Allergies: Statins: Hmg-Coa Reductase Inhibitors / Prednisone / Albuterol Attending:[First Name3 (LF) 2387] Chief Complaint: Palpitations Major Surgical or Invasive Procedure: Attempted PVI History of Present Illness: 74 M w/ recent admission for afib w/ [Hospital 5509] transferred from OSH in afib w/ RVR (HR 160s-180s) now controlled on dilt ggt. Already planning for PVI tomorrow. In the ED, initial vitals:Time 19:42 0 97.4 80-100 119/86 18 95-97 on 2L. EKG afib w/ LBBB, similar to prior. Dilt ggt at 10 mg/ hr. HR now in low 100s. On arrival to the floor, he converted to SR in the 80s. He states that the palpitations began yesterday morning and they awakened him from sleep, along w/ increased dyspnea. Denies cp/f/c. Occasional cough. He denies orthopnea or pnd although he notes that he sleeps more comfortably on his R side. He endorses chronic L leg pain for which he takes vicodin. On review of systems, s/he denies any prior history of deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: -Stroke, no residual effects -atrial fibrillation -diverticulitis w colonic perf, s/p post partial colon resection -R ankle fusion, chronic pain -severe chronic obstructive pulmonary disease ([2166-2-13] PFTs: FEV1 0.86L; 28%pred, FEV1/FVC 67% pred) -prostate cancer s/p radiation therapy -hypertension -hypercholesterolemia -gastroesophageal reflux disease -right middle lobe pneumonia in [2160] -diabetes mellitus -status post herniorrhaphy -status post cholecystectomy, with apparently complicated course (30 day hospital stay) -chondroid lesion of left upper arm (~10 cm) - incidentally discovered in [1-/2167] -left cataract -right central blind spot in vison Social History: Smokes [1-2] ppd. Has been smoking for the past 63 years (3ppd). He does not drink alcoholic beverages. The patient is recently widowed. He is retired from the air force and from work in real estate. Family History: No family history of early MI, otherwise non-contributory. Physical Exam: VS - 138/61, 87, 20, 96% on RA. 221.3 lbs Gen: WDWN middle aged male in NAD but appears mildly dyspneic. Oriented x3. Mood, affect appropriate. Face plethoric. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 10 cm. CV: 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 mildly labored but he was speaking in full sentences w/o accessory muscle use. Scant bibasliar crackles. Occasional expiratory wheezes bilaterally. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Midline ventral hernia. Ext: No c/c/e. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Left: Carotid 2+ feet warm but non-palp pedal pulses Pertinent Results: TTE [2167-4-14]: Focused study: Initially, there is a moderate sized pericardial effusion. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. Towards the end of the study, there is resolution of the effusion with only a trivial amount remaining and improvement in right ventricular filling. Compared with the prior study (images reviewed) of [2167-3-3], the pericardial effusion is new. The current study only consists of limited views and cannot be compared to the prior echocardiogram. TTE [2167-4-15]: Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is mild to moderate global left ventricular hypokinesis (LVEF = 35-45 %). The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [2167-4-14], the findings are similar. The size of the effusion is similar. Renal US [2167-4-17]: 1. No hydronephrosis. 2. 1.2 cm right kidney angiomyolipoma. 3. Echogenic liver consistent with fatty infiltration. However other forms of liver disease and more advanced liver diseased (i.e. cirrhosis/fibrosis) cannot be excluded. CXR [2167-4-21] In comparison with the study of [4-17], substantial enlargement of the cardiac silhouette persists but there is no evidence of congestive failure. Small amount of opacification in the right costophrenic angle could reflect some atelectasis or residual effusion. No evidence of acute focal pneumonia. Head CT [2167-4-22]: No acute intracranial process. [2167-4-13] 08:10PM BLOOD WBC-9.7 RBC-4.75 Hgb-15.2 Hct-44.6 MCV-94 MCH-32.0 MCHC-34.1 RDW-13.7 Plt Ct-224 [2167-4-22] 06:30AM BLOOD WBC-8.0 RBC-3.43* Hgb-10.7* Hct-32.2* MCV-94 MCH-31.3 MCHC-33.3 RDW-14.0 Plt Ct-373 [2167-4-13] 08:10PM BLOOD Neuts-61.7 Lymphs-28.9 Monos-5.3 Eos-3.5 Baso-0.6 [2167-4-22] 06:30AM BLOOD PT-25.9* PTT-26.9 INR(PT)-2.6* [2167-4-22] 06:30AM BLOOD Glucose-161* UreaN-60* Creat-2.0* Na-141 K-4.7 Cl-98 HCO3-33* AnGap-15 [2167-4-17] 03:50AM BLOOD Glucose-175* UreaN-69* Creat-3.8* Na-138 K-4.2 Cl-104 HCO3-22 AnGap-16 [2167-4-13] 08:10PM BLOOD Glucose-141* UreaN-31* Creat-1.1 Na-142 K-4.1 Cl-102 HCO3-31 AnGap-13 [2167-4-15] 06:08AM BLOOD ALT-82* AST-101* AlkPhos-44 TotBili-0.9 [2167-4-14] 07:15AM BLOOD CK(CPK)-66 [2167-4-22] 06:30AM BLOOD proBNP-2927* [2167-4-15] 01:37AM BLOOD CK-MB-3 cTropnT-0.02* [2167-4-22] 06:30AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.1 [2167-4-14] 05:53PM BLOOD Triglyc-296* [2167-4-17] 03:50AM BLOOD Digoxin-0.9 Brief Hospital Course: 74yo M with with multiple admissions for difficult to control AF with RVR, admitted for PVI, but hospital course complicated by cardiac tamponade, VT arrest, ATN, CHF and altered mental status. #. Atrial fibrillation: Patient was admitted after converting to NSR in ED. He went for PVI. Prior to ablation he developed hypotension and tachycardia. A stat TTE revealed pericardial effusion and tamponade. He had a JP drain placed and drained 1300mL. A repeat tte showed trivial effusion. After this he had several follow up TTEs with no change in the trivial effusion and no evidence of tamponade. On admission to the CCU he was in NSR, however, over the course of the night he began to have runs of tachycardia consistent with his previous episodes of afib. He then developed a wide complex tachycardia and was pulseless. He received 3 shocks, epinephrine, vasopressin, and amiodarone bolus followed by an amiodarone drip after he regained a pulse. He was continued on the amiodarone drip as well as a diltiazem drip for rate and rhythm control, and transitioned to oral amiodarone and oral diltiazem. After transfer out of ICU, pt continued to go into and out of afib, with adequate rate control on up-titrated diltiazem, metoprolol and amiodarone. # Systolic Heart Failure: On TTE patient was noted to have new low EF. Unclear if this was secondary to tachycardia induced CM vs ischemic CM vs (most like) effect of VT arrest/shocks/compressions. Further evaluation was deferred until pt given time to recover. Would recommend repeat TTE in 1 month to reassess for residual function and decide course accordingly. In the setting of this new CHF and positive fluid balance and minimal urine output, pt became significantly volume overloaded with new pulmonary edema. He was diuresed successfully with lasix. On discharge, CXR was improved, but BNP was still elevated. Pt's lisinopril was held in the setting of renal failure. # ARF: Patient developed rise in creatinine after poor perfusion due to tamponade and VT arrest. Renal was consulted and thought he likely had ATN from hypotension. Renal ultrasound showed no evidence of obstruction but a 0.2 cm right kidney angiomyolipoma. #. COPD: Pt was intubated for PVI and successfully extubated the next day. He was treated with his home inhalers. There was no evidence of superimposing infection or flair. #. DM2: Pt's home glipizide was held while in-house, covered w/ SS humalog #. Hyperlipidemia: continue ezetemibe, fenofibrate #. Chronic L-leg pain: Was maintained on his longstanding home narcotic regimen. #. Altered Mental Status: In the ICU and on the floor, pt was repeatedly disoriented, inappropriate and disinhibited. This was thought to be multifactorial, including contribution from multiple new meds, hospital relocating, and likely hypoperfusion of frontal lobe during tamponade/code blue. CT head was obtained and showed no acute bleed. Multiple meds were held, including narcotics, without significant effect on his demeanor. Family confirmed that he was far from his baseline but he gradually improved throughout the stay. At discharge, pt was alert and oriented x 3, aware of his situation and story, but occasionally fabricating. #. Urinary retention: Pt had pain at site of foley requiring removal but repeatedly retained urine requiring reinsertion. This was thought to be due to pt's baseline prostate disease and recurrent catheter trauma. On discharge pt had received 2 days of flomax and had been without foley for 48 hrs without difficulty. #. Gerd: Ranitidine Medications on Admission: per [2167-4-3] D/C summary, confirmed w/ patient. 1. Dofetilide 250 mcg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 2. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation [Hospital1 ] (2 times a day). 3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 4. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: Three (3) ML Inhalation q6h () as needed for shortness of breath. 5. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:30 Capsule, Sustained Release(s) Refills:2 6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 7. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 14. Glipizide Oral 15. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day as needed for cold symptoms. 16. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) puff Inhalation twice a day. 2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. 3. Diltiazem HCl 180 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:2 8. 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 9. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:30 Tablet(s) Refills:2 10. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 12. Xopenex HFA 45 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation Q6H (every 6 hours). Disp:120 puff Refills:2 13. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 15. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Discharge Disposition: Home With Service Facility: VNA Assoc. of [Hospital3 ] Discharge Diagnosis: Primary: Atrial Fibrillation Secondary: Pericardial Tamponade, Ventricular Tachycardia Arrest, Acute tubular necrosis, Acute Systolic CHF Discharge Condition: Stable, chest pain free Discharge Instructions: You were admitted for atrial fibrillation, an arrhythmia that makes your heart beat irregularly and fast. You underwent a procedure to control this arrhythmia but had a complication which required you being monitored in the ICU. You then developed another arrhythmia which we were able to reverse with compressions, shock, and a new medication. Since then you recovered quite well - we've been able to control your heart rate with medications, and have removed fluid off of your lungs with a water pill. Please take medications as prescribed on the list provided below. A visiting nurse will help organize the new medication regimen. If you develop chest pain, shortness of breath or any other concerning symptoms, please call Dr [Last Name (STitle) 11679] or return to the hospital. It was a pleasure taking care of you, we wish you the best! Followup Instructions: Please follow up with Dr [Last Name (STitle) 11679] on Monday [5-4], 2:30. Please have your INR checked on Monday [5-27]. Completed by:[2167-4-28]	[ "788.29", "780.97", "428.21", "427.31", "V12.54", "496", "423.9", "530.81", "423.3", "584.5", "272.4", "V10.46", "250.00", "428.0", "V64.1", "427.1" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	12904, 12965	6248, 8830	336, 352	13148, 13174	3508, 6225	14074, 14240	2481, 2541		11293, 12881		12986, 13127		9826, 11270				13198, 14051													2556, 3489																										284, 298							380, 1541											8845, 9800						1563, 2244	2260, 2465
29,156	161,773	6031	Discharge summary	report	Admission Date: [2100-6-9] Discharge Date: [2100-6-19] Date of Birth: [2028-4-23] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1674] Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: intubation R IJ central line placement History of Present Illness: Mr. [Known lastname 724] is a 72 year old Cantonese-speaking male brought in from rehab for respiratory distress. History is limited as the patient is cantonese speaking only. In the ED, his vital signs were stable, and he was maintaining adequate oxygen saturation, but he was intubated for increased work of breathing and a NG tube was placed for feeding. A CXR was performed whichi showed no signficant signs of infiltrate or edema. The patient was given solumedrol and combivent inhalers for possible COPD flare. Lactate was within normal limits, there was no leukocytosis, and the first set of cardiac enzymes were negative. The patient was also given a dose of Levaquin for UTI on UA. The family was not able to be contact[Name (NI) ] in the [Name (NI) ]. . On review of his chart, notes from the rehab indicate that the patient was noted to be congested and SOB, with O2 sats 87-94% on 2 liters NC. The patient coughed up copious secretions as well. He recently completed 5 day course of Ceftriaxone for UTI. The patient was recommended for transfer to the ED for further evaluation, also noted to be full code. Past Medical History: (limited, obtained from medical chart) COPD trigeminal neuralgia GERD muscle weakness lung nodule dementia anemia Social History: Resident at [Hospital6 ], son is next of [Doctor First Name ] Family History: non-contributory Physical Exam: VS: 97.6 121/73 90 20 96% 2L GEN: cachectic elderly man lying in bed, int coughing HEENT: atraumatic, anicteric, pupils reactive, equal, OP clear, dried blood from a raw patch on his lips, OP clear, MMM, neck supple CV: regular, no murmurs or rubs LUNGS: scattered rhonchi at bases B/L, distant breath sounds, patient not cooperative with exam ABD: thin, soft, non-tender, non-distended, + BS EXT: decreased muscle tone, no lower extremity edema. Feet cool, DP pulses +2 BL NEURO: sleepy, responds to voice Pertinent Results: [2100-6-8] 11:45PM BLOOD WBC-6.9 RBC-3.03* Hgb-9.7* Hct-28.8* MCV-95 MCH-31.9 MCHC-33.6 RDW-14.7 Plt Ct-426 [2100-6-11] 05:11AM BLOOD WBC-8.6 RBC-2.95* Hgb-9.5* Hct-28.2* MCV-96 MCH-32.4* MCHC-33.8 RDW-14.7 Plt Ct-449* [2100-6-12] 12:14AM BLOOD WBC-11.1* RBC-3.13* Hgb-9.9* Hct-30.1* MCV-96 MCH-31.7 MCHC-32.9 RDW-14.7 Plt Ct-464* [2100-6-14] 05:09AM BLOOD WBC-13.0* RBC-2.96* Hgb-9.4* Hct-28.6* MCV-97 MCH-31.7 MCHC-32.9 RDW-14.8 Plt Ct-480* [2100-6-17] 05:22AM BLOOD WBC-11.9* RBC-3.45* Hgb-10.8* Hct-33.3* MCV-97 MCH-31.3 MCHC-32.5 RDW-14.9 Plt Ct-746* [2100-6-18] 05:23AM BLOOD WBC-10.3 RBC-3.14* Hgb-10.0* Hct-30.2* MCV-96 MCH-32.0 MCHC-33.3 RDW-14.9 Plt Ct-557* [2100-6-8] 11:45PM BLOOD Neuts-74.6* Lymphs-16.4* Monos-4.1 Eos-4.8* Baso-0.2 [2100-6-10] 03:47AM BLOOD Neuts-91.3* Bands-0 Lymphs-4.7* Monos-2.2 Eos-0.5 Baso-1.3 [2100-6-9] 12:27AM BLOOD PT-12.4 PTT-28.9 INR(PT)-1.1 [2100-6-10] 03:47AM BLOOD PT-13.2* PTT-30.0 INR(PT)-1.2* [2100-6-8] 11:45PM BLOOD Glucose-113* UreaN-9 Creat-0.6 Na-134 K-5.7* Cl-96 HCO3-36* AnGap-8 [2100-6-14] 05:09AM BLOOD Glucose-117* UreaN-16 Creat-0.6 Na-135 K-4.6 Cl-96 HCO3-36* AnGap-8 [2100-6-16] 04:19PM BLOOD Glucose-119* UreaN-30* Creat-0.7 Na-135 K-5.2* Cl-96 HCO3-30 AnGap-14 [2100-6-18] 05:23AM BLOOD Glucose-127* UreaN-25* Creat-0.5 Na-131* K-4.5 Cl-96 HCO3-29 AnGap-11 [2100-6-8] 11:45PM BLOOD CK-MB-4 cTropnT-<0.01 [2100-6-8] 11:45PM BLOOD CK(CPK)-131 [2100-6-9] 03:40AM BLOOD CK-MB-5 cTropnT-<0.01 [2100-6-9] 03:40AM BLOOD CK(CPK)-116 [2100-6-11] 05:11AM BLOOD CK-MB-3 cTropnT-<0.01 [2100-6-11] 05:11AM BLOOD CK(CPK)-43 [2100-6-11] 03:30PM BLOOD CK-MB-2 cTropnT-<0.01 [2100-6-11] 03:30PM BLOOD CK(CPK)-44 [2100-6-14] 05:09AM BLOOD ALT-39 AST-26 LD(LDH)-179 AlkPhos-60 TotBili-0.2 [2100-6-9] 03:40AM BLOOD Calcium-7.8* Phos-2.6* Mg-1.8 [2100-6-18] 05:23AM BLOOD Calcium-8.8 Phos-2.7 Mg-2.3 [2100-6-14] 05:09AM BLOOD Triglyc-112 [2100-6-15] 08:25AM BLOOD Vanco-12.4 [2100-6-9] 12:26AM BLOOD Type-ART Temp-35.6 Rates-/16 Tidal V-400 pO2-504* pCO2-78* pH-7.27* calTCO2-37* Base XS-6 -ASSIST/CON Intubat-INTUBATED [2100-6-9] 07:16AM BLOOD Type-ART Rates-24/24 Tidal V-445 PEEP-5 FiO2-80 pO2-362* pCO2-49* pH-7.40 calTCO2-31* Base XS-4 AADO2-168 REQ O2-37 Intubat-INTUBATED Vent-IMV [2100-6-10] 06:15AM BLOOD Type-ART Rates-/15 Tidal V-540 PEEP-5 FiO2-40 pO2-94 pCO2-48* pH-7.45 calTCO2-34* Base XS-7 Intubat-INTUBATED [2100-6-13] 06:12AM BLOOD Type-ART Temp-37.3 Rates-/24 Tidal V-528 PEEP-5 pO2-84* pCO2-57* pH-7.44 calTCO2-40* Base XS-11 -ASSIST/CON Intubat-INTUBATED [2100-6-15] 07:00PM BLOOD Type-ART pO2-106* pCO2-51* pH-7.45 calTCO2-37* Base XS-9 [2100-6-16] 05:31PM BLOOD Type-ART pO2-81* pCO2-42 pH-7.45 calTCO2-30 Base XS-4 Intubat-NOT INTUBA [2100-6-9] 12:36AM BLOOD Lactate-0.9 [2100-6-9] 03:57AM URINE Color-STRAW Appear-SLHAZY Sp [Last Name (un) ]-1.015 [2100-6-9] 03:57AM URINE Blood-SM Nitrite-POS Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD [2100-6-9] 12:27AM URINE RBC-21-50* WBC-21-50* Bacteri-MOD Yeast-NONE Epi-0-2 . MICRO URINE CULTURE (Final [2100-6-14]): PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML.. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Trimethoprim/Sulfa sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| STAPH AUREUS COAG + \| \| CEFEPIME-------------- 4 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R <=0.5 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- =>8 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R PIPERACILLIN---------- 8 S PIPERACILLIN/TAZO----- 8 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- S VANCOMYCIN------------ <=1 S . Legionella Urinary Antigen (Final [2100-6-9]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). . [2100-6-9] 3:40 am BLOOD CULTURE Source: Venipuncture. FINAL REPORT [2100-6-15] AEROBIC BOTTLE (Final [2100-6-15]): NO GROWTH. ANAEROBIC BOTTLE (Final [2100-6-15]): NO GROWTH. . Time Taken Not Noted Log-In Date/Time: [2100-6-9] 5:16 am SPUTUM Site: ENDOTRACHEAL FINAL REPORT [2100-6-12] GRAM STAIN (Final [2100-6-9]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): YEAST(S). RESPIRATORY CULTURE (Final [2100-6-12]): SPARSE GROWTH OROPHARYNGEAL FLORA. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. ACINETOBACTER BAUMANNII. MODERATE GROWTH. "Note, for Amp/sulbactam, higher-than-standard dosing needs to be used, since therapeutic efficacy relies on intrinsic activity of the sulbactam component". STAPH AUREUS COAG +. MODERATE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Trimethoprim/Sulfa sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ACINETOBACTER BAUMANNII \| STAPH AUREUS COAG + \| \| AMPICILLIN/SULBACTAM-- =>32 R CEFEPIME-------------- 16 I CEFTAZIDIME----------- =>64 R CIPROFLOXACIN--------- =>4 R CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=1 S <=0.5 S IMIPENEM-------------- 8 I LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- 2 S VANCOMYCIN------------ <=1 S . [2100-6-10] 3:47 am BLOOD CULTURE Source: Venipuncture. FINAL REPORT [2100-6-16] AEROBIC BOTTLE (Final [2100-6-16]): NO GROWTH. ANAEROBIC BOTTLE (Final [2100-6-16]): NO GROWTH. . IMAGING: CXR port [6-8]: FINDINGS: An endotracheal tube terminates approximately 5 cm superior to the carina. A nasogastric tube can be seen with tip beyond the field of view of the film. The side port is also beyond the view of the film. The heart is normal in size. The mediastinal and hilar contours are unremarkable. The aorta is mildly ectatic. There is flattening of the diaphragm consistent with mild hyperinflation. Diffuse reticular opacities are present consistent with underlying emphysematous change. The soft tissues and osseous structures are otherwise unremarkable. No pleural effusion is seen. Biapical disease with retraction of the hila and reticular opacities within the lungs. There is evidence of prior granulomatous disease. IMPRESSION: Status post intubation and nasogastric tube placement, both in appropriate position. Hyperinflation and reticulonodular opacities consistent with underlying emphysema and old granulomatous disease. Clinical correlation is recommended. No acute cardiopulmonary disease present. . CXR [6-12]: One portable view. Comparison with [2100-6-11]. The lungs remain clear. The costophrenic sulci are blunted, as before. The lungs appear hyperinflated. The heart and mediastinal structures are unremarkable. An endotracheal tube and nasogastric tube remain in place. There is no significant change. IMPRESSION: No significant interval change. . CXR [6-16]: AP BEDSIDE CHEST. Heart is normal in size without vascular congestion, consolidations, effusions, or hilar/mediastinal enlargement. This patient has had daily chest radiographs since [2100-6-8]. Since exam one day ago, the ET and NG tubes have been removed. IMPRESSION: No acute disease. . CXR [6-17]: Cardiomediastinal contour is unchanged. There is a tiny right apical pneumothorax. Right subclavian vein catheter tip is in unchanged position in the SVC. Right supraclavicular subcutaneous emphysema is unchanged. The lungs are hyperinflated, but clear. There are no pleural effusions. . EKG [6-9]: Sinus rhythm. Electrocardiographic findings are within normal limits. No previous tracing available for comparison. Brief Hospital Course: MICU COURSE: Pt was admitted to MICU with hypercarbic respiratory failure requiring intubation. He was found to have MRSA and pseudomonas pneumonia and COPD flare. After extubation he developed recurrent respiratory failure requiring BiPap. His family made the decision to make patient DNR/DNI. While in th MICU the patient complained of chest pain and so MI was ruled out with insignificant EKG and negative CEs x 3. The MICU team felt that the pain was mostly likely secondary to history of shingles (post herpetic neuralgia), per son. Once he was extubated he refused to eat and on further discussions with son, it was revealed that patient had been refusing to eat for the past several months, taking in only minimal calories per day. He refused NG tube and was started on TPN. As patient had such poor baseline status and was recovering so slowly, family and MICU team began to discuss CMO, with involvement of palliative care team. It was decided that decision re: CMO would have to include his eldest son who would fly to the USA from [Location (un) 6847]. On the night before the son arrived, patient appeared stable from a respiratory and mental status standpoint. He was transferred to th general medicine floor. On arrival to floor, VSS and patient refused chest pain or sob. On routine vitals check several hours later, he was found without respirations. pronounced dead. His right IJ line was pulled out from the skin and there was approx 300cc of blood around that area and on the bed sheets. After a long discussion with the family, in which autopsy was requested, this was refused. Case was reported to the QI committee. Medications on Admission: advair albuterol spiriva zyprexa 5 mg [Hospital1 ] protonix 40 mg neurontin 300 mg TID aricept 10 mg daily meclizine 12.5 mg carbamazepine 200 mg [Hospital1 ] iron multivitamin megace Discharge Disposition: Expired Discharge Diagnosis: na Discharge Condition: na Discharge Instructions: na Followup Instructions: na [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 1677] Completed by:[2100-6-30]	[ "530.81", "482.41", "294.8", "041.7", "518.81", "491.22", "053.12", "482.1", "263.9", "285.9", "599.0" ]	icd9cm	[ [ [] ] ]	[ "96.04", "38.93", "96.72", "99.15", "96.6" ]	icd9pcs	[ [ [] ] ]	13925, 13934	12027, 13682	335, 375	13980, 13984	2338, 12004	14035, 14190	1777, 1795				13955, 13959		13708, 13902				14008, 14012													1810, 2319																										275, 297							403, 1536																	1558, 1674	1690, 1761
69,323	180,244	519	Discharge summary	report	Admission Date: [2199-7-13] Discharge Date: [2199-7-16] Date of Birth: [2116-9-4] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4309] Chief Complaint: chest pain Major Surgical or Invasive Procedure: none History of Present Illness: 82F h/o prior CVA with residual R-sided weakness, AS ([Location (un) 109] 1.2 cm2), cecal and splenic flexure masses admitted with chest pain. Describes 3 days of chest pain that radiates across the chest, occuring only while supine at night, describes as a constant "punching" sensation, lasting multiple hours, and resolving either spontaneously or with tylenol. Pain is similar in character, but more severe, compared to prior episodes (most recently many months ago). Had one episode of nonbloody emesis. No associated dizziness, lightheadedness, palpitations, shortness of breath, diaphoresis, dyspepsia, edema, or positional/exertional component. Son also reports seeing bright red blood on the bed sheets two days ago (not since). When pain recurred for the 3rd straight night, she presented to the ED. Initial V/S 97.6 79 129/45 16 99%RA. Brown stool guaiac+. . Labs notable for Hct 21.6 (31.9 on [5-28]) CK 41 MB 3 trop <0.01. Had CP in the ED, at which time EKG showed ~1mm ST elev in aVR with new ST dep in I,II,L,V2-V6. Given ASA 325, morphine 2 mg (with resolution of pain), protonix 40 mg IV. EKG changes improved with resolution of pain. Given [1-24] unit pRBC then called by blood bank to say that Ab+ so transfusion stopped. Pain-free, with vital signs prior to transfer 97.5 66 124/60 12 100%4L . Upon transfer to the floor on [7-14], patient was a symptomatic without chest pain, dizziness, shortness of breath, or active bleed. Past Medical History: -L MCA infarct [2181], residual R sided deficits -AS ([Location (un) 109] 1.1 cm2 by TTE [3-2]) -HTN -Carotid stenosis -Moderate pulm HTN -Cecal and splenic flexure mass ([4-1] Bx showed superficial fragments of colonic mucosa with rare dilated crypts, granulation tissue formation and focal ulceration = may be seen overlying/adjacent to a mass lesion or may represent superficial sampling of an inflammatory-type polyp) -Diverticulosis -Internal hemorrhoids Social History: H/o tobacco use. 3 children (2 sons, 1 daughter, son in [Name (NI) 4310] assists w/ care), many grandchildren. Walks w/ a cane at baseline. Uses meals on wheels. VNA services weekly. Family History: Mother d. ca, Father d. CAD, children healthy Physical Exam: V/S T 96.5 83 128/94 13 100%2L. GEN: Awake, alert, conversing appropriately HEENT: PERRL, lower loose-fitting dentures, dry MM NECK: No JVD CV: reg rate nl S1S2 III/VI SEM at base radiates to carotids LUNGS: CTAB no w/r/r ABD: soft NTND normoactive BS EXT: warm, dry +PP no edema NEURO: AAOX3 Pertinent Results: Admission Labs: . [2199-7-13] 06:30AM PLT COUNT-396 [2199-7-13] 06:30AM NEUTS-66.5 LYMPHS-24.5 MONOS-5.6 EOS-2.9 BASOS-0.5 [2199-7-13] 06:30AM WBC-6.5 RBC-2.40# HGB-6.7# HCT-21.6# MCV-90 MCH-28.1 MCHC-31.2 RDW-19.5 [2199-7-13] 06:30AM MAGNESIUM-2.1 [2199-7-13] 06:30AM CK-MB-3 [2199-7-13] 06:30AM cTropnT-<0.01 [2199-7-13] 06:30AM CK(CPK)-41 [2199-7-13] 06:30AM estGFR-Using this [2199-7-13] 06:30AM GLUCOSE-105* UREA N-35* CREAT-1.2* SODIUM-143 POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-23 ANION GAP-15 [2199-7-13] 02:35PM HCT-20.8* [2199-7-13] 02:35PM CK-MB-3 cTropnT-<0.01 [2199-7-13] 02:35PM CK(CPK)-31 [2199-7-13] 03:30PM PT-12.2 PTT-22.6 INR(PT)-1.0 [2199-7-13] 10:23PM PT-12.8 PTT-23.4 INR(PT)-1.1 [2199-7-13] 10:23PM HCT-27.1# [2199-7-13] 10:23PM CK-MB-3 cTropnT-<0.01 [2199-7-13] 10:23PM CK(CPK)-33 . Discharge Labs: . [2199-7-16] 07:20AM BLOOD WBC-6.8 RBC-3.53 Hgb-10.7* Hct-32.3* MCV-92 MCH-30.4 MCHC-33.2 RDW-17.4* Plt Ct-296 [2199-7-16] 07:20AM BLOOD Glucose-98 UreaN-15 Creat-0.9 Na-142 K-4.1 Cl-109* HCO3-25 AnGap-12 [2199-7-16] 07:20AM BLOOD Calcium-7.8* Phos-2.6* Mg-2.1 [2199-7-15] 07:00AM BLOOD CEA-2.4 . Studies: . EKG [2199-7-13] 13:39:28 (pain-free) SR 80 bpm possible LVH downsloping 1 mm STD II TWF III 2-3 mm downsloping STD in V3-V6 . Imaging: [2199-7-13] PA/LAT Evaluation is suboptimal, due to patient rotation and underpenetration. Mild vascular congestion has resolved. The lungs are clear without focal consolidation. Moderate cardiomegaly persists, with a slightly tortuous aorta. Dense calcifications are present in the mitral annulus. Mild degenerative changes are present in the thoracic spine. IMPRESSION: No acute cardiopulmonary process. Brief Hospital Course: 82F h/o CVA, AS, known colonic masses admitted with chest pain at rest and global ischemic EKG changes in the setting of acute on chronic blood loss anemia. Admitted to the MICU on [7-13], transferred to the floor on [7-14], discharged on [7-16]. . #Acute on chronic blood loss anemia - Patient was admitted to the MICU with chest pain x 3 days after son had noticed a significant amount of blood in her bed. On admission, Hct was found to be 20. She was transfused 4U and hct stabilized in the low 30s where it remained for admission. She spent one night in the MICU and was transferred to the floor on HOD #2. The source of her bleeding has not been confirmed, but differential includes hemmhoroidal, diverticular, or from masses in her cecum an splenic flexure which were found on colonoscopy in [3-/2199] (likely malignant). She was followed by both surgery and GI in-house and both agreed that she would likely need surgical intervention for the masses but acknowledged that she had a high surgical risk (aortic stenosis, history of CVA). She remained hemodynamically stable on the floor, but did have an episode of BRBPR on HOD#3 with a hct drop from 31.6-->29.9. She remained asymptomatic with this episode and did not require PRBC. A tagged red blood cell scan was deferred given that she was asymptomatic. She was discharged on HOD#4 with follow-up in the geriatrics clinic for further discussion of options for her colonic masses. She was informed to return to the ED if her symptoms of chest pain return, or if she has significant bleeding. . #Chest pain/EKG changes - Along with BRBPR, patient presented with chest pain , and an EKG with diffuse ST depressions, suggestive of global ischemia in the setting of profound anemia, likely a demand ischemia. Her pain resolved with blood transfusions. Aspirin 81 mg was restarted, and beta blockade was also started, and she continued to receive her statin. She continued to remain asymptomatic from a cardiac standpoint throughout transfer to floor and remainder of admission. . #Colonic masses- Seen by both surgery and GI in-house. Both agreed that surgical intervention was likely warranted given high likelyhood of malignancy from her cecal/splenic flexure masses. However her comorbidities make her an increased surgical risk, especially in the setting of her recent acute bleed. Decision was made by the primary team to have her follow up with geriatrics the following week to discuss options. . #HTN - On admission to the MICU, she was started beta blockade and her lisinopril/dilt were held in the setting of the bleed. Lisinopril was restarted upon transfer to the floor on [7-14]. Metoprolol was continued through her discharge day, and she was discharged on her diltiazem at home dose with instructions to have her home health aid to check her blood pressure as an outpatient. . Medications on Admission: Lisinopril 10 mg daily Simvastatin 20 mg daily Verapamil 240 mg daily Ferrous sulfate 325 mg daily ASA 81 mg Vit D Vit C Fish Oil MVI Omega-3 Discharge Medications: 1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Outpatient Lab Work Please check CBC on [7-17] or [7-18]. Fax results to Dr. [First Name8 (NamePattern2) 4311] [Last Name (NamePattern1) 4312] at [Telephone/Fax (1) 716] 3. Omega-3 Fatty Acids-Fish Oil 300-1,000 mg Capsule Sig: Three (3) Capsule PO three times a day. 4. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 6. Vitamin D-3 400 unit Tablet Sig: One (1) Tablet PO three times a day. 7. Vitamin C 250 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Tablet, Delayed Release (E.C.)(s) 9. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day: Please have your blood pressure checked by your home health aide prior before restarting this medication. 10. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary Lower Gastrointestinal Bleed Anemia Demand ischemia Colonic masses Diverticulosis Hemmorhoids Secondary Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [Known lastname ] [Known lastname 4313], You were admitted to the hospital because you were having chest pain and blood in your stool causing you to become anemic (low blood counts). We feel that the anemia was likely the cause of your chest pain because you improved when you were transfused with blood. You spent one night in the intensive care unit and were then transferred to the general medical floor where you have done well. You did have a few episodes of bleeding again yesterday but your blood count remained stable and you were not experiencing any symptoms from it. We feel that the blood in your stool is coming from your colon, but the surgery and gastrointestinal teams saw you and felt that surgery was not warranted at this point. Please note that you may continue to have more blood in your stool, but that this is likely old blood and should not cause symptoms. If you do have any symptoms of chest pain, shortness of breath, or increasing blood loss please come back to the emergency room. Please wait to restart your verapamil until you have your blood pressure checked by your home health aide later this week. If your blood pressure is normal (or high) you can restart this medication. You should continue to take all of your other medications as previously prescribed and listed below. Please note your scheduled appointment with Dr. [Last Name (STitle) 4312] below. She will help to coordinate your care with your specialists. Please have your son accompany you to this appointment. We also request that you have lab work done tomorrow or Thursday. We have written you a perscription for this and you can return to our lab to have this done. Followup Instructions: Department: GERONTOLOGY When: TUESDAY [2199-7-23] at 3:45 PM With: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 719] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "280.0", "438.89", "729.89", "578.1", "416.8", "285.1", "424.1", "414.9", "433.10", "569.9", "401.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	8916, 8973	4749, 7633	325, 331	9143, 9143	2920, 2920	11013, 11382	2544, 2591		7825, 8893		8994, 9122		7659, 7802				9294, 10990					3849, 4726								2606, 2901																										275, 287							359, 1824						2936, 3833					9158, 9270						1846, 2323	2339, 2528
77,429	162,654	27664	Discharge summary	report	Admission Date: [2155-9-16] Discharge Date: [2155-9-22] Date of Birth: [2109-11-1] Sex: M Service: ORTHOPAEDICS Allergies: Gentamicin Attending:[First Name3 (LF) 64] Chief Complaint: Post-operative hypotension Right hip heterotopic ossification Major Surgical or Invasive Procedure: resection arthroplasty, right hip History of Present Illness: 45 year old male with history of T4 paraplegia,admitted for R hip girdlestone resection arthroplasty to improve mobility. Past Medical History: -T4 paraplegia from MVA age 28, [2137] -IBD -VRE, MRSA ([2153]), polymicrobial infections; followed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] ID fellow bb12672 (clinic number [Telephone/Fax (1) 39041]) at [Hospital1 756] -h/o urosepsis and chronic indwelling foley with multiple false passages of urethra; foley changes require urology involvement -h/o osteomyelitis on chronic suppressive abx -Stage IV sacral ulcer decubiti and bilateral ischial ulcers and -left trochanteric ulcers s/p debridement [2154-6-21] -Chronic pain on narcotics -Iron deficiency anemia -Peripheral neuropathy (ulnar) -GERD -GIB secondary to hemorrhoids Past Surgical History (as summarized in ortho note) -[2155-4-23], Surgical preparations of very large sacral and left trochanteric wounds with STSG and VAC placement -[2155-1-28], developed wound breakdown posterior thoracic spine surgery area, at which time he had a complex wound exploration with debridement and removal of posterior thoracic instrumentation with a wound washout and complex closure by plastic surgery in combination with neurosurgery. I&D of the paraspinal abscess and placement of a large VAC sponge was completed. - [9-/2154] s/p surgical preparation of left trochanteric and ischial ulcers and local tissue rearrangement and advancement with coverage of trochanteric and ischial ulcers exceeding 160 cm2 - [8-/2154] s/p thoracic wound revision with a washout and removal of hardware for postoperative cervical, thoracic wound infection with failure of instrumentation from progressive osteomyelitis -[2154-8-14] s/p lateral extracavitary transpedicular T9-T10 corpectomy for debridement of spinal abscess and bony infection with a T6-L1 posterior spinal instrumentation fusion - [5-/2154] s/p debridement decubitus ulcers - [2146] s/p Girdlestone procedure L hip [2146] at [Hospital1 756] [2136]?3 s/p tracheostomy at time of MVA [2136]?3 s/[Initials (NamePattern4) ] [Last Name (NamePattern4) 931] rods placement Social History: He lives alone in [Location (un) 2268], uses VNA services, has a son, requires a personal care attendant four hours a day. On disability. States he is anxious and claustrophobic by limited mobility at home. - Tobacco: denies - Alcohol: denies - Illicits: denies Family History: Mom with HTN, DM, heart failure Physical Exam: On iCU Admission: General: Alert, oriented, speaking in full sentences, interactive, appears in mild discomfort HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, unable to appreciate JVP, no LAD Lungs: Clear to auscultation bilaterally anteriorly, no wheezes, rales, ronchi CV. Regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Foley draining clear yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Contracted. DP/PT 1+ B/L. R hip with dsg C/D/I. Pertinent Results: [2155-9-16] 07:46PM GLUCOSE-127* UREA N-13 CREAT-0.5 SODIUM-140 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-30 ANION GAP-11 [2155-9-16] 07:46PM estGFR-Using this [2155-9-16] 07:46PM ALT(SGPT)-25 AST(SGOT)-32 LD(LDH)-185 CK(CPK)-401* ALK PHOS-150* TOT BILI-0.9 [2155-9-16] 07:46PM CK-MB-5 cTropnT-0.02* [2155-9-16] 07:46PM ALBUMIN-2.9* CALCIUM-8.1* PHOSPHATE-5.0* MAGNESIUM-1.7 IRON-94 [2155-9-16] 07:46PM calTIBC-181* FERRITIN-287 TRF-139* [2155-9-16] 07:46PM WBC-9.4 RBC-3.67* HGB-10.8* HCT-32.5* MCV-89 MCH-29.5 MCHC-33.3 RDW-13.1 [2155-9-16] 07:46PM PLT COUNT-239 [2155-9-16] 05:39PM TYPE-ART PO2-139* PCO2-50* PH-7.39 TOTAL CO2-31* BASE XS-4 [2155-9-16] 05:39PM GLUCOSE-110* LACTATE-2.1* NA+-140 K+-3.5 CL--98* [2155-9-16] 05:39PM HGB-14.1 calcHCT-42 [2155-9-16] 05:39PM freeCa-1.15 [2155-9-16] 05:18PM WBC-7.1 RBC-3.76* HGB-11.1* HCT-34.1* MCV-91 MCH-29.6 MCHC-32.6 RDW-12.9 [2155-9-16] 05:18PM PLT COUNT-270 [2155-9-16] 05:18PM PT-13.4 PTT-34.7 INR(PT)-1.1 [2155-9-16] 05:18PM FIBRINOGE-419* Brief Hospital Course: The patient was admitted to the orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: 1.Hypotension: Patient presenting with post-operative hypotension which is likely multifactorial. Differential diagnosis includes hypovolemia, sepsis, medication effect. Tachycardia and hypotension with responsiveness to fluids and drop in HCT from 32 to 25 despite 1 unit PRBCs suggest more likely hypovolemic/hemorrhagic. 2. Tachycardia: Likely related to blood loss in addition to self-reported anxiety 3. UTI: Per outpt ID doc: h/o recurrent ESBL Klebs in urine only sensitive to carbepenems. Has also received fosfomycin for lower tract disease but in setting of recent surgery/instrumentation would cover for now with [Last Name (un) 2830] while awaiting cx. Asked foley to be changed and will repeat UA. Also always has >200WBC on UA. FYI: Also has h/o acinetobacter and pseudomonas and bugs [Last Name (un) 36] to only colistin, asked us to avoid PICC at all costs since tends to seed them. Discharged on Meropenem x 14 days. Otherwise, pain was initially controlled with a PCA followed by a transition to oral pain medications. The patient received lovenox for DVT prophylaxis. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. At time of discharge, patient was deemed stable for safe discharge to rehab. Medications on Admission: Home Medications Confirmed with patient: Doxycycline 100mg PO BID BACLOFEN 10 mg PO daily prn OXYCONTIN 40 mg Tablet Sustained Release 12 hr PO q8 hours OXYCODONE-ACETAMINOPHEN [ENDOCET] - 5 mg-325 mg Tablet - [1-1] Tablet(s) by mouth four or five times a day as needed for breakthrough pain to not take tylenol in addition. ASCORBIC ACID - 500 mg Tablet - 1 Tablet(s) by mouth twice a day FERROUS SULFATE - 325 mg PO q day-[Hospital1 ] MULTIVITAMIN - 1 Tablet(s) by mouth once a day . Discharge Medications: 1. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily) for 3 weeks. Disp:21 Refills:0 2. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 3. oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q8H (every 8 hours). Disp:40 Tablet Sustained Release 12 hr(s) Refills:0 4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for breakthru. Disp:80 Tablet(s) Refills:0 5. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 14 days. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: pain right hip due to heterotopic ossicification 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: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. 5. Please keep your wounds clean. You may shower starting five days after surgery, but no tub baths or swimming for at least four weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by the visiting nurse or rehab facility two weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment in four weeks. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for three weeks to help prevent deep vein thrombosis (blood clots). After completing the lovenox, please take Aspirin 325mg TWICE daily for an additional three weeks. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by the visiting nurse or rehab facility in two weeks. 11. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks, and staple removal at two weeks after surgery. 12. ACTIVITY: PROM as tolerated with PT Physical Therapy: PROM OK Treatments Frequency: dresssing changes 2-3 times daily as needed-DSD Followup Instructions: Provider: [First Name11 (Name Pattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3260], [MD Number(3) 3261]:[Telephone/Fax (1) 1228] Date/Time:[2155-10-17] 1:00 Completed by:[2155-9-22]	[ "458.29", "344.1", "285.1", "707.03", "354.9", "707.24", "530.81", "996.64", "728.13", "599.0", "E879.6", "718.55", "280.9" ]	icd9cm	[ [ [] ] ]	[ "77.85" ]	icd9pcs	[ [ [] ] ]	7974, 8040	4716, 6812	335, 371	8133, 8133	3605, 4693	10791, 11023	2917, 2952		7356, 7951		8061, 8112		6838, 7333				8309, 10034													2967, 3586	10688, 10696	10718, 10768																								234, 297				10046, 10670			399, 523											8148, 8285						545, 2615	2631, 2901
32,442	191,391	45045	Discharge summary	report	Admission Date: [2156-1-20] Discharge Date: [2156-1-29] Date of Birth: [2080-6-2] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 13561] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 75M with a hx of progressive dysphagia, shortness of breath within the past 2 weeks who was transferred to [Hospital1 18] from [Hospital3 ] for further evaluation of an undiagnosed progressive muscular disorder. . In the ED, the patient's NIF was noted to be 24. After speaking with the respiratory therapist it had since trended down to 10. CXR was concerning for left lower lobe pneumonia. The patient was started on Levaquin and Flagyll. . During his admission to [Hospital1 ]Hospital he was seen by speech and swallow. He was noted to have mild to moderate oropharyngeal dysphagia. A fiberoptic endoscopic evaluation of swallowing (FEES study) was performed which showed severe pharyngeal dysphagia. ENT saw the patient and felt that he could tolerate a full liqiuid diet. The patient was also noted to be dyspneic at rest. He had a high O2 requirement ( 4L, non-rebreather, BiPAP--for CO2 retention). Neurology also saw the patient and they were concerned about lower motor neuron disease most likely ALS with bulbar symptoms. The patient's course was complicated by afib w/ RVR which responded to diltiazem. . Specifically, has had difficulty swallowing for almost 10 years and weight loss of 60 pounds in the past year or so. More recently had been having trouble bringing up secretions. And also had to give himself the Heimlich maneuver 4 times prior to presentation. Notes change in his voice low to higher pitch. . He's noted worsening dyspnea without orthopnea, LE edema or history of heart failure. Does have extensive smoking history 50-60 years 1PPD and used to drink 4-5 beers/day. Gets short of breath walking down the [Doctor Last Name ]. . ROS: Gen: 60 pound wt loss slightly over a year Card: no chest pain Pulm: shortness of breath GI: daughter notes several severe choking episodes Neuro: progressive neuromuscular weakness, difficulty walking Past Medical History: Progressive Neuromuscular Disorder of unknown etiology prior to this admission Recent treatment for aspiration pneumonia atrial fibrillation with RVR oropharyngeal dysphagia dyspnea on BPAP 30 minutes four x daily HOH, usually uses left hearing aid (recently broken) Social History: 30 pack year smoking history, extensive alcohol use (per daughter over 50yrs). [Name2 (NI) ] worked as a foreman and may have been exposed to chemicals. Family History: unknown to patient Physical Exam: MICU admission PE: T 96 HR 89 BP 115/82 R 23 O2 95% 2L GEN: at rest he appears comfortable, when speaking for prolonged period of time appears to be working slightly to breath HEENT: extremely dry mucous membranes, OP clear HEART: nl rate, S1S2, no gmr LUNGS: bronchial breath sounds ABD: positive bowel sounds, no guarding, no rebound tenderness EXT: thin, warm and well perfused NEURO: PERRLA, II-XII grossly intact, tongue midline, 5/5 strength in upper and lower extremity, 1+ brachioradialis, 1+ patellar reflexes bilaterally, sensation to light touch is intact NEUROLOGY ADMISSION PE: T- 98 BP- 117/70 HR- 62 RR- 22 96 O2Sat 4L NC, nif -24 VC 1L Gen: Sitting up straight in stretcher, very HOH, mildly out of breath when speaking HEENT: NC/AT, moist oral mucosa, TMs wnl Neck: supple, no carotid or vertebral bruit CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Bibasilar crackles to auscultation aBd: +BS soft, nontender ext: no edema Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place, and date. Attentive, says [Doctor Last Name 1841] backwards. Speech is fluent with normal comprehension and repetition; naming intact. Mild dysarthria. [Location (un) ] intact. Registers [1-26], recalls [12-28] w/clues [1-26] w/choices in 5 minutes. No right left confusion. No evidence of apraxia or neglect. Cranial Nerves: Pupils round and reactive to light, R 4 to 2mm and L 3 to 2mm. Visual fields are full to confrontation. Extraocular movements intact bilaterally, no nystagmus. Sensation intact V1-V3. Bifacial weakness with fasciculations of left eye lid, upper lip and tongue. Decreased hearing R>L. Palate elevation symmetrical. Sternocleidomastoid and trapezius normal bilaterally. Tongue midline. Motor: Atrophy of hand muscles bilaterally. Tone normal. Fasciculations in pectoralis, deltoids, biceps, hand muscles and quadriceps. No pronator drift [Doctor First Name ] Tri [Hospital1 ] WF WE FE FF IO IP H Q DF PF TE TF R 4 5 4 5 5- 5- 4+ 5- 5- 5 5 5 5 4 5 L 5 5 5 5 5 5 5 5- 5- 5 5 5 5 4 5 Sensation: Intact to light touch, cold and proprioception throughout. Decreased vibration R (absent toe, intact at ankle) >L (toe [1-27] secs). Reflexes: Tri [Hospital1 ] Br Pat Ach R 2+ 0 0 2 0 L 2+ 2 2 2 0 Toes downgoing bilaterally Coordination: finger-nose-finger normal, heel to shin normal, RAMs normal. Gait: Narrow based, normal stride but associated with severe dyspnea. Romberg: Negative Pertinent Results: CT torso: 1. A combination of atelectasis, aspiration, and superimposed pneumonia is noted in the lung bases. There is also associated asbestos-related pleural plaque calcification. 2. Right lower lobe nodule that needs to be followed up by CT scan examination in six months. 3. A small left pleural effusion and smaller right pleural effusion is noted. 4. Hyperplastic left adrenal gland. 5.Superior wall thickening of the urinary bladder.Cystoscopic evaluation is recommended. . EMG: Complex, abnormal study. There is electrophysiologic evidence for a moderate, generalized, predominantly axonal, sensorimotor polyneuropathy. In addition, there are severe, widespread denervation/chronic reiinervation changes which cannot be explained by polyneuropathy. These findings are consistent with a disorder of motor neurons or their axons (as in amyotrophic lateral sclerosis). . Video swallow: Moderate-to-severe pharyngeal dysphagia with reduced opening of the upper esophageal sphincter. A small amount of aspiration identified on today's study, although tougher solids were not administered and would likely produce larger amounts of aspiration. . CT c-spine: 1. Moderate-to-severe cervical spondylosis predominating from C4 through C7 with central canal narrowing and neural foraminal narrowing as described. Evaluation of thecal detail is limited on CT and if clinically indicated, MRI can be pursued. 2. Sinus mucosal disease with evidence of right mastoid air cell opacification of unknown chronicity. Clinical consideration for mastoiditis and sinusitis should be considered. 3. Emphysema and scarring at the lung apices bilaterally. . CXR: 1. Patchy opacities involving the left lower lobe concerning for aspiration, pneumonia or a combination. 2. Likely pleural plaques identified suggesting prior asbestos exposure. . MRI cspine: FINDINGS: There is no evidence of fracture. There is reversal of the normal cervical spine lordosis in the upper cervical spine. Vertebral body heights are normal, but there is loss of intervertebral disc space height at multiple levels, most prominently at C4/5, C5/6, and C6/7. There is degenerative retrolisthesis in conjunction with reversal of lordosis at these levels as well. There is mild-to-moderate multilevel degenerative disease extending from C2/3 through C6/7, with mild-to-moderate spondylotic ridging at multiple levels, as well as moderate bilateral uncovertebral osteophyte formation. There is mild- to- moderate central canal stenosis along this entire length, most severe at C5/C6. There is mild neural foraminal narrowing on the left at C3/4, and C4/5. There is marked thickening of the ligamentum flavum at multiple levels, and thickening of the posterior longitudinal ligament, most prominent at C1/2. IMPRESSION: Mild-to-moderate cervical spondylosis extending from C2/3 to C6/7, secondary to multilevel spondylotic ridging and uncovertebral osteophyte formation, most severe at C5/6, where there is moderate ventral indentation of the thecal sac. . MRI brain: FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or infarction. No diffusion abnormality is detected. The ventricles and sulci are normal in size and configuration. There are scattered foci of mild FLAIR signal hyperintensity in the periventricular and subcortical white matter, most consistent with chronic small-vessel ischemic disease. There is no abnormal enhancement after contrast administration. There is moderate mucosal thickening, with mild peripheral enhancement in the left maxillary sinus. Note is also made of fluid within the bilateral mastoid air cells, right greater than left, and a small amount of fluid in the right middle ear. Incidental note is made of moderate degenerative disease of the cervical spine, better evaluated on dedicated cervical spine MRI, concurrently performed. IMPRESSION: 1. No evidence of brainstem abnormality, or other finding relating to ALS. 2. Moderate left maxillary sinus mucosal thickening, bilateral mastoid air cell opacification, and right middle ear fluid may relate to sinusitis. Please correlate clinically. 3. Degenerative disease of the cervical spine, better evaluated and reported separately in concurrently performed MRI of the cervical spine. . EKG: Baseline artifact. Atrial fibrillation with moderate ventricular response. Borderline left axis deviation. Poor R wave progression, probably a normal variant. No previous tracing available for comparison. . . Vitamin b12: 1657 MMA 108 (normal) TSH: 2.6 FT4: 1.0 Brief Hospital Course: 75 y/o man presented with shortness of breath in the setting of progressive neuromuscular disease. . 1. Shortness of breath: The patient was admitted to the MICU with breathing difficulty secondary to underlying neuromuscular weakness, as demonstrated by clear paradoxical breathing on exam. Patient was also found to have a question of pneumonia on chest X-ray and likely atelectasis. Video swallow with dysphagia. Monitored in the ICU by NIFs and VCs which were stable. Patient clear about desire not to be intubated. Treated with levofloxacin for aspiration pneumonia for two days, but in the absence of fever and leukocytosis, the internal medicine team stopped this medication prior to transfer out of the MICU to neurology service. DNR/I status was confirmed with the patient, and he tolerated bipap at night for sleep with nasal mask, settings [6-29] with 2L O2. He should be continued on this setting at night until further notice, as it ensures that he is awake and comfortable during daytime hours. . 2. Neuromuscular disorder: He was evaluated by neurology as an inpatient. He had an EMG that demonstrated the new diagnosis of motor neuron disease, thought to be most likely consistent with ALS. He had a torso CT scan to evaluate for malignancy for ? paraneoplastic syndrome leading to symptoms. CT c-spine demonstrated spondylosis but thought to be only a minor contributor to symptoms. Bladder wall thickening was seen, and urology recommended an outpatient cystoscopy (not to be done emergently). He also had a sub-centimeter pulmonary nodule that will need to be re-assessed in 3 months if the patient desires. He had an MRI of the brain and Cspine; MRI of the brain showed some chronic opacification of sinuses, and MRI of the cspine showed multi-level disc disease with foraminal stenosis at many levels. Though this can cause lower motor neuron signs and symptoms (including fasciculations, as he has), it did not explain his bulbar symptoms, and thus ALS was felt to be the more likely diagnosis. Several discussions were held with the patient and with his stepdaughter, and they wished to change the goals of care to comfort measures. He will decide in the future if he wants certain disease processes worked up or treated, but for now, the goal is comfort. Hospice options were explored and the patient was discharged to a nursing home with hospice services. If there are any remaining questions or concerns about the diagnosis, Dr. [First Name8 (NamePattern2) 518] [Last Name (NamePattern1) 575] (neurology, BIMDC) has agreed to answer questions and see him in follow-up if needed. . 3. Dysphagia: The patient's dysphagia was felt to be related to ALS. He declined PEG tube placement, despite the knowledge that he was at risk for aspiration with a modified diet, and considering the knowledge that ALS is a progressive disease with no cure. . 4. Atrial fibrillation: Aspirin was continued for protection from stroke, considering his atrial fibrillation, as a disabling stroke (ie, hemiplegia with aphasia) was felt to likely impair his quality of life. 5. Pt pulled out his foley catheter while in the ICU. After this, he complained of penile pain. He was treated with tylenol - small effect; lidocaine jelly and pyridium (last day of admission) = no effect. Pyridium was not continued upon discharge. 6. diarrhea noted upon arrival from ICU. he was checked for cdiff--> found to be negative; empirically started on flagyl while awaiting cdiff. Flagyl was d/c'ed prior to discharge to hospice. Medications on Admission: Albuterol/Ipratropium neb q6h ASA 81 QD Dulcolax 10mg PR QD Diltiazem 100mg [Hospital1 ] Advair inh [Hospital1 ] Folate 1mg QD HSC 5000U TID Metoprolol 12.5mg q6h Morphine Sulfate 1mg q3hrs PRN dyspnea MVI Senna 2 tabs QHS Thiamine 100mg QD Trazodone 25mg QHS PRN Ceftriaxone 1gm/Flagyl 500mg q6H until [1-19] Discharge Medications: 1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO QID (4 times a day) as needed. 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed: use as suppository or orally - part of "comfort pack.". 5. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed. 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 7. Acidophilus Tablet, Chewable Sig: One (1) Tablet, Chewable PO Qday (). 8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea: use as suppository or orally - part of "comfort pack.". 9. Benadryl 25 mg Capsule Sig: 0.5 Capsule PO every six (6) hours as needed for nausea: use as suppository or orally - part of "comfort pack.". 10. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea: use as suppository or orally - part of "comfort pack.". 11. Reglan 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea: use as suppository or orally - part of "comfort pack.". 12. Haloperidol Lactate 2 mg/mL Concentrate Sig: 0.5 mL mL PO every six (6) hours as needed for agitation: sublingual. 13. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1) Sublingual every six (6) hours as needed for secretions: part of "comfort pack.". 14. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for agitation: part of "comfort pack.". 15. Morphine Concentrate 20 mg/mL Solution Sig: Fifteen (15) mL PO every four (4) hours as needed for pain: =5mg/dose; part of "comfort pack." Also PRN breathlessness. 16. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea: part of "comfort pack.". 17. Prochlorperazine 25 mg Suppository Sig: One (1) Rectal every six (6) hours as needed for nausea: part of "comfort pack.". Discharge Disposition: Extended Care Facility: [Location (un) 31427] House (Hospice Home) - [Hospital1 8] Discharge Diagnosis: Amyotrophic Lateral Sclerosis Aspiration pneumonia - resolved Polyneuropathy Bladder wall thickening seen on CT torso Discharge Condition: Fair - swallows with some risk of aspiration but declines PEG placement; on hospice medication regimen; continues to have widespread fasiculations of face, tongue and limbs; some upper and lower motor neuron pattern of weakness in arms and legs. Mild sensory changes at the feet. Discharge Instructions: Please follow up with your hospice specialists; we have also scheduled you a visit with a primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ]. Your appointment will be in [Month (only) 547] and you will need transportation to and from the appointment. If there are any problems with health and particularly neurological issues pertaining to the ALS, please contact the office of Dr. [First Name8 (NamePattern2) 518] [Last Name (NamePattern1) 575] ([Telephone/Fax (1) 96296]) or ask page operator at [Hospital1 18] to page neurology resident on call ([Telephone/Fax (1) 2756]). Followup Instructions: You will need a follow-up CT of the chest in 6 months to evaluate a right lower lobe lung nodule. You should also have an outpatient cystoscopy of the bladder (primary care may schedule) to evaluate for bladder wall thickening, as recommended by urology. We have scheduled you a visit with a primary care physician at [Hospital6 733] - Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], [3-3] at 2:30PM. [Hospital Ward Name 23] [Location (un) 453], [Hospital1 18]. Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 43501] [Name12 (NameIs) 40719], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2156-3-3] 2:30 If you have new neurological problems that you are concerned about, please contact Dr. [First Name8 (NamePattern2) 518] [Last Name (NamePattern1) 575] ([Telephone/Fax (1) 96296]) or ask page operator at [Hospital1 18] to page neurology resident on call ([Telephone/Fax (1) 2756]). You may schedule an appointment to see Dr. [Last Name (STitle) 575] at your convenience (will be a 'new' appointment). Completed by:[2156-1-29]	[ "335.20", "V66.7", "427.31", "721.0", "356.9", "V11.3", "787.91", "507.0", "518.81", "596.9" ]	icd9cm	[ [ [] ] ]	[ "93.90" ]	icd9pcs	[ [ [] ] ]	15989, 16082	9961, 13514	344, 350	16244, 16526	5402, 9938	17208, 18350	2748, 2768		13887, 15966		16103, 16223		13540, 13864				16550, 17185													2783, 3738																										285, 306							378, 2267	4212, 5383										3777, 4196			3762, 3762			2289, 2558	2574, 2732
11,746	136,984	19225+19226+19227	Discharge summary	report+report+report	Admission Date: [2146-4-2] Discharge Date: [2146-4-18] Date of Birth: [2088-11-15] Sex: M Service: NEUROMEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 57 year-old man with a history of hypertension who was transferred from [Hospital3 6454] Hospital with a right frontal parietal intracerebral hemorrhage in the setting of elevated blood pressure. He had presented to [Hospital3 1280] with a one day history of headache and was found to be hypertensive to 250/130. He continued to complain of a severe headache, but did not have any obvious neurological deficits. A head CT was performed and showed a large right frontal parietal intracerebral hemorrhage with intraventricular extension. He was therefore transferred to the [Hospital1 69]. In route the patient became agitated and was intubated for "airway protection." PAST MEDICAL HISTORY: Hypertension. MEDICATIONS: None. ALLERGIES: Bee stings. SOCIAL HISTORY: The patient is divorced. He has three children. He had been living in [State 4565] and was incarcerated for a period of time for alleged drunk driving. He recently moved back to the [Location (un) 86] area and was living with his mother. There is no smoking. He had a history of alcohol abuse. PHYSICAL EXAMINATION ON ADMISSION: Blood pressure 140/70 on Nipride. Pulse 80s. Respiratory rate 18. In general, the patient was intubated and sedated. Neck was supple. His lungs were clear. Heart was regular rate and rhythm. Neurological examination the patient moved all extremities to loud verbal stimulation. He was not following commands. On cranial nerves the pupils were 1.5 mm and minimally reactive. He had intact corneals and oculocephalics. On motor testing there was increased tone in the lower extremities. He moved all extremities symmetrically to noxious stimulation. On sensory examination he withdrew to pain in all four extremities. His reflexes were symmetrical. His toes were upgoing bilaterally. Head CT no admission showed a large intraparenchymal hemorrhage in the right frontal/parietal lobe approximately 3.5 cm in size with surrounding edema. There was intraventricular extension with a small amount of hemorrhage in the occipital horns bilaterally. There was compression of the atrium and tip of the [Doctor Last Name 534] of the right lateral ventricle. HOSPITAL COURSE: The patient was therefore admitted to the Intensive Care Unit for further treatment. The patient has had a long and complicated course as follows. 1. Neurological: The patient was evaluated by the Neurosurgical Service. An angiogram was performed on [4-3], which showed no evidence of aneurysm or arterial vascular malformation. The patient's initial blood pressure goal was less then 140 and this was maintained with drips as needed. These parameters were gradually liberated to less then 160. The patient was initially moving all extremities. He was extubated shortly after arrival. He then became very agitated with increasing blood pressures. In order to maintain his blood pressure in a safe range the patient was reintubated and sedated. Given the patient's significant alcohol history it was felt that this likely represented alcohol withdraw. The patient was therefore placed on a CIWA scale and given Ativan accordingly. The patient was successfully sedated. Sedation was then lifted. The patient subsequently has not shown any signs of neurological improvement. Serial head CTs showed little change in the size of the hemorrhage and surrounding edema. The patient's depressed mental status was most likely due to several factors including left lower lobe pneumonia, transaminitis, dehydration with uremia, bacteremia and stroke as outlined below. On [4-16] the patient underwent MRI. Diffusion weighted images showed several areas of restrictive diffusion bilaterally in the periventricular region consistent with multiple small acute infarcts. The area of hemorrhage in the right frontal parietal region was unchanged, unsusceptibly and several small areas of chronic blood products in both cerebral hemispheres. There was no enhancement with gadolinium. This most likely represented bilateral water shed infarcts in the setting of an episode of hypotension following reintubation several days prior to the scan. Other possibilities included amyloid angiopathy or endocarditis with septic embolic infarcts. Endocarditis is being worked up further as below. The patient's current neurological examination is he has his eyes closed most of the time. He is able to slowly open his eyes to loud verbal stimulation. His pupils are equally round and reactive to light. His oculocephalic and corneals are intact. He has decreased tone throughout. He has little to no spontaneous movements. He shows minimal withdraw on the right side to noxtious stimulation. 2. Cardiovascular: The patient's initial blood pressure parameters were less then 140 and these were liberated slowly to less then 160. He has intermittently been on several drips including Nipride and labetalol and maintained his goal pressure. Oral antihypertensives were gradually introduced and currently include Lopressor, Enalapril, Norvasc, Lasix as well as a Clonidine patch. The patient still remains hypertensive requiring prn intravenous blood pressure medications. On approximately [4-16] the patient went into atrial flutter with 2 to 1 block. This was refractory to Lopressor and Diltiazem. The patient was therefore cardioverted. He again went into atrial flutter requiring cardioversion and started on Amiodarone drip. This is now being converted to po Amiodarone. The patient had an echocardiogram on [4-18], which showed moderately dilated left atrium, moderately dilated right atrium, moderate symmetric left ventricular hypertrophy, mildly dilated aortic root, mild mitral regurgitation and mild tricuspid regurgitation. Left ventricular ejection fraction is greater then 55%. There was no visualized thrombus or vegetation. The plan at this time is for a transesophageal echocardiogram. 3. Respiratory: The patient had been intubated prior to arrival. He was quickly extubated. However, he was reintubated due to increasing agitation and the need for sedation in order to control his blood pressures. He was again successfully extubated, however, this patient had increasing difficulty with handling his secretions requiring frequent suctioning. He showed progressive signs of respiratory distress and was reintubated on approximately [4-12]. He currently remains intubated on CPAP with pressure support and plans are for a tracheostomy. 4. Fluids, electrolytes and nutrition: The patient was initially on intravenous fluids and then was started on tube feeds. The patient showed progressive signs of intravascular depletion with rising BUN to a high of 74 on [4-15] and a high creatinine of 1.6. This was most likely due to insensible losses from tachypnea. After intubation and fluid repletion in the form of free water boluses due to the nasogastric tube these have gradually improved and the most recent values as of [4-18] are a BUN of 34 and a creatinine of 1. The patient's electrolytes were repleted as needed. 5. Gastrointestinal: The patient's liver function tests were normal on admission. These were checked frequently given his encephalopathic state. His liver function tests gradually increased to a peak of ALT 773 and AST 484 on [4-11]. The Liver Service was consulted and the most likely etiology was felt to be Dilantin. The Dilantin was discontinued and his liver function tests have subsequently improved with his most recent values of ALT 195 and AST 65. For workup of his transaminitis a right upper quadrant ultrasound was obtained. This revealed air in the biliary tract and gallbladder lumen. As there was no known history of gastrointestinal procedures to account for this the Surgical Service was consulted. The patient underwent abdominal and pelvic CT, which confirmed the presence of the air in the common bile duct, gallbladder and hepatic duct. However, there were no findings of ischemic bowel. His clinical presentation was not consistent with infection. Therefore the patient was restarted on tube feeds and has been sable from an abdominal standpoint. The patient remains on gut protection with a proton pump inhibitor. His stools have become guaiac positive in will be continued to be followed. 6. Hematology: The patient's hematocrit gradually decreased over the course of admission from 39.8 to 29.7 on [4-15]. He had a significant decrease from [4-14] to [4-15] going from 38.1 to 29.7. It was felt that this was most likely due to fluid resuscitation. Hematocrit has remained stable since. The patient's stools have been guaiac positive and this will continue to be followed. 7. Infectious disease: The patient showed signs of likely aspiration pneumonia on chest x-ray. His sputum grew pan sensitive staph aureus. The patient was treated with a 14 day course of Ceftriaxone. On [4-14] blood cultures grew out coagulase negative staph. The patient was started on Vancomycin for this and remains on Vancomycin as of this dictation. In summary, the patient is a 57 year-old male with a history of hypertension who presented with intracerebral right frontal parietal hemorrhage with intraventricular extension. He has had a long and complicated subsequent course as detailed above. It si still felt that the most likely etiology of his hemorrhage is hypertension. Vascular malformations and aneurysms have not been apparent in conventional angiography. There is no suggestion of an underlying mass on MRI. The other etiologies still in consideration and being worked up are amyloid angiopathy and endocarditis. The patient has remained comatose most likely due to his factors as stated above. His most active current medical issues include recent atrial flutter and coagulase negative staph bacteremia. Plans are for PEG and trach placement this week. DIAGNOSES: 1. Right frontal parietal intracerebral hemorrhage. 2. Stroke. 3. Atrial flutter. 4. Hypertension. 5. Dehydration. 6. Transaminitis. 7. Pneumonia. 8. Staph epidermitis bacteremia. [Name6 (MD) 4267] [Last Name (NamePattern4) 4268], M.D. [MD Number(1) 4269] Dictated By:[Doctor Last Name 52386] MEDQUIST36 D: [2146-4-18] 06:35 T: [2146-4-20] 14:18 JOB#: [Job Number 52387] Admission Date: [2146-4-2] Discharge Date: [2146-4-18] Date of Birth: [2088-11-15] Sex: M Service: NEUROMEDICINE ADDENDUM TO HOSPITAL COURSE: With regard to the atrial flutter it was recommended informally by cardiology that the patient get a whole week of Amiodarone 400 mg po b.i.d. and then switch to 400 mg po q.d. starting on [2146-4-25]. From there on he would take 400 mg q.d. for a week and on [5-2] start 200 mg po q.d. indefinitely until he was to follow up Dr. [Last Name (STitle) ] in the Cardiology Clinic at [Hospital1 346]. He will also be receiving [Initials (NamePattern4) ] [Last Name (NamePattern4) ] of Hearts cardiac monitor, which will need to be pressed several times a day by the nursing home staff since the patient is unable to do so. This is done to monitor for bradycardia or other atrial flutter events while he is there as an outpatient. A clinic follow up date will be arranged for him in cardiology and will be written on discharge paperwork. If there are no clinic dates set up we will provide all phone numbers for health care providers that will be following up with this patient. [Name6 (MD) 4267] [Last Name (NamePattern4) 4268], M.D. [MD Number(1) 4269] Dictated By:[Name8 (MD) 4064] MEDQUIST36 D: [2146-4-21] 11:33 T: [2146-4-21] 11:56 JOB#: [Job Number 52388] Admission Date: [2146-4-2] Discharge Date: [2146-4-21] Date of Birth: [2088-11-15] Sex: M Service: NEUROMED ADDENDUM: This is an addendum to the previously dictated discharge summary. HOSPITAL COURSE CONTINUED: 1. NEUROLOGICAL: The patient's neurological examination improved slightly to the point that his eyes were open and he appeared to be awake, although he did not track visual stimuli including examiner's faces. His pupils still remained round and reactive to light. He did have oculocephalic and corneal reflexes. He again had little to no spontaneous movements of his extremities but there was noted to be some withdrawal on the right side to noxious stimulation as well as some minimal withdrawal on the left leg to noxious stimulation. As a result of the appearance of the MRI which showed bilateral watershed infarcts, there was some suspicion for potential endocarditis causing multiple embolic events. A transesophageal echocardiogram was performed which showed no vegetations consistent with endocarditis. Given the history of the positive blood cultures, this was felt necessary to rule this out and after the TEE was done this was felt not likely to be the diagnosis. These infarcts are presumed to be from an episode of hypotension during the [Hospital 228] hospital course in which his systolic blood pressures dipped down to 70. 2. CARDIOVASCULAR: As mentioned before, the patient had been cardioverted from A flutter to normal sinus rhythm on Amiodarone. He will continue on a daily maintenance dose of Amiodarone. He had no further events of A flutter. The patient had cardiac enzymes done to rule out myocardial ischemia as being the cause for atrial flutter and these did not suggest any myocardial ischemia. The patient was on a multitude of blood pressure lowering medications including Clonidine, Norvasc, Lasix, Enalapril, and metoprolol. He was eventually switched over to simplify the regimen to just labetalol and Enalapril and probably could increase the doses of those medications should his blood pressure not stay well controlled under systolic blood pressure of 160 or less. 3. RESPIRATORY: The patient still remains ventilated and had received a tracheostomy on [2146-4-20]. 4. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was placed on Lasix standing 20 mg b.i.d. However, it was noticed that his BUN to creatinine ratio was rising on the order of 30 or above. Furosemide was discontinued to allow the patient's fluid status to re-equilibrate. Initially this was done to try to prevent any fluid overload that would compromise his ability to come off the ventilator. 5. GASTROINTESTINAL: As mentioned before, the patient had a transaminitis which was felt to be due to Dilantin. His transaminases have continued to come down and on the day before discharge the patient's LFTs came down to ALT 107, AST 50, alkaline phosphatase 82, and total bilirubin 0.3. 6. The patient continues to have an anemia of unclear etiology. His crit has been stable in the high 20s. In part, this is probably likely due to anemia of chronic disease; however, iron studies are still pending at this time. 7. INFECTIOUS DISEASE: The patient was being treated for an aspiration pneumonia immediately that was pansensitive Staphylococcus aureus. He finished a course of ceftriaxone for this. As mentioned, he had a coagulase-negative staphylococcal infection in his blood for which he was on vancomycin for a total of 14 days. DISCHARGE DIAGNOSIS: As in the previous discharge summary. DISCHARGE MEDICATIONS: 1. Multivitamins one cap p.o. q.d. 2. Folic acid 1 mg p.o. q.d. 3. Bisacodyl 10 mg p.o. q.d. p.r.n. constipation. 4. Nystatin ointment applied topically q.i.d. to effected areas as needed. 5. Enalapril 20 mg p.o. b.i.d. 6. Thiamine 100 mg p.o. q.d. 7. Lansoprazole 30 mg p.o. q.d. 8. Amiodarone 400 mg p.o. q.d. 9. Heparin 5,000 units subcutaneously q. 12 hours. 10. Labetalol 100 mg p.o. t.i.d. 11. Vancomycin 1 gram IV q. 12 hours for eight additional days to end on [2146-4-28]. CONDITION ON DISCHARGE: Fair. DISCHARGE STATUS: To rehabilitation. FOLLOW-UP: The patient should follow-up in the stroke clinic in about two months time. [Name6 (MD) 4267] [Last Name (NamePattern4) 4268], M.D. [MD Number(1) 4269] Dictated By:[Name8 (MD) 4064] MEDQUIST36 D: [2146-4-20] 04:43 T: [2146-4-20] 18:47 JOB#: [Job Number 52389]	[ "790.7", "518.82", "507.8", "276.0", "401.0", "427.32", "431", "482.41", "434.91" ]	icd9cm	[ [ [] ] ]	[ "96.6", "31.1", "96.72", "88.72", "96.04", "88.41", "38.93", "43.11", "03.31" ]	icd9pcs	[ [ [] ] ]									15628, 16124		15566, 15605			10760, 15545																																																	175, 878									1322, 2389								901, 962	979, 1307	16149, 16535
13,476	142,468	13045	Discharge summary	report	Admission Date: [2151-7-3] Discharge Date: [2151-7-12] Date of Birth: [2068-9-14] Sex: M Service: MEDICINE Allergies: Shellfish / latex Attending:[First Name3 (LF) 2763] Chief Complaint: Mechanical Fall/R Hip Fracture Major Surgical or Invasive Procedure: Fixation with short trochanteric fixation nail (TFN) and cephalomedullary nail, 11 x 170 x 130. History of Present Illness: 82 year old with COPD, non-small cell lung cancer s/p RUL lobectomy, MI s/p stent placement, likely diastolic CHF and prostate cancer admitted on [7-3] for right femoral neck fracture after a mechanical fall. Patient originally presented to OSH and was subsequently transferred here for further evaluation and treatment of hip fracture. Of note patient has severe COPD at baseline that has worsened during this time, also. He generally walks without assistance, hunched over and is unable to climb more than one flight of stairs without significant SOB, able to walk across a room but slowly. Patient and family states his limitation with exertion is all pulmonary (dyspnea, weakness) and he has not had any chest pain, sore throat, presyncope, syncope with any exertion. In the ED initial VST 97.8, HR78, BP 152/77, RR12, O2Sat96% on RA. Pelvis and Femur imaging confirmed right femur fracture. Orthopedics Surgery evaluated the patient in the ED and recommended admission to Medicine for comorbidity management, pre-operative risk stratification. Past Medical History: * Severe COPD (FEV1 26% predicted in [2145]) * Right upper lobe adenocarcinoma s/p lobectomy, [2146] * Coronary artery disease s/p MI with PTCA coronary stent in the '90s * Diastolic CHF (EF 65% in [2147]) * Hypertension * Hyperlipidemia * Prostate cancer * Gout * Osteoarthritis * Bowel perferation from colonoscopy and pooly healing percutaneous fistula/ventral hernia - course also complicated by difficult extubation, (Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], [12/2147]/[2148]) * AAA Repair (Dr. [Last Name (STitle) 1391], [2133]) * Bilateral inguinal hernia repair [2137] X2 * Tonsillectomy * Hypothyroidism Social History: Retired and married - lives with wife denies tobacco/alcohol/illicit drugs but previous 50 pack year history for smoking, quit in [2133]. Daughter and son-in-law involved in his care. Family History: [Name (NI) 2280], father also had lung cancer Physical Exam: Admission exam: VS - Temp 97.9F, BP 190/86, HR 88, R 88, O2-sat 92% RA GENERAL - Elderly man in NAD, comfortable, appropriate, falls asleep easily during conversation HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - Supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, decreased breath sounds, increased AP diameter, slow expiratory phase, resp unlabored, no accessory muscle use HEART - PMI non-displaced, irregularly irregular, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs); Significant tenderness to palpation of latero-posterior right leg and with manipulation of it; shortened and externally rotated SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact, strength and sensation grossly intact Pertinent Results: [2151-7-7] 08:55AM BLOOD Hct-24.2 [2151-7-7] 02:37AM BLOOD WBC-8.7 RBC-1.74* Hgb-6.2* Hct-19.5* MCV-112* MCH-35.7* MCHC-31.7 RDW-18.5* Plt Ct-113* [2151-7-6] 11:13PM BLOOD Hct-21.7* [2151-7-6] 02:27PM BLOOD WBC-17.1* RBC-2.11* Hgb-7.4* Hct-23.5* MCV-112* MCH-35.0* MCHC-31.4 RDW-18.2* Plt Ct-146* [2151-7-6] 10:48AM BLOOD Hct-23.6* [2151-7-6] 08:45AM BLOOD Hct-UNABLE TO [2151-7-6] 07:35AM BLOOD WBC-19.4* RBC-2.00* Hgb-7.1* Hct-22.7* MCV-113* MCH-35.2* MCHC-31.1 RDW-18.3* Plt Ct-126* [2151-7-5] 07:05PM BLOOD WBC-19.7* RBC-2.25* Hgb-7.8* Hct-25.2* MCV-112* MCH-34.9* MCHC-31.2 RDW-18.3* Plt Ct-118* [2151-7-5] 06:00AM BLOOD WBC-15.4* RBC-2.24* Hgb-7.8* Hct-25.0* MCV-112* MCH-34.6* MCHC-31.1 RDW-18.1* Plt Ct-120* [2151-7-4] 07:30AM BLOOD WBC-12.9* RBC-2.29* Hgb-8.1* Hct-25.5* MCV-112* MCH-35.4* MCHC-31.8 RDW-18.0* Plt Ct-146* [2151-7-3] 07:45PM BLOOD WBC-14.1* RBC-2.47# Hgb-8.7 Hct-27.1* MCV-110# MCH-35.3 MCHC-32.1 RDW-17.7* Plt Ct-161 [2151-7-6] 02:27PM BLOOD Neuts-76.5* Lymphs-7.3* Monos-15.4* Eos-0.4 Baso-0.4 [2151-7-3] 07:45PM BLOOD Neuts-81.8* Lymphs-7.2* Monos-10.7 Eos-0.2 Baso-0.2 [2151-7-7] 02:37AM BLOOD PT-11.1 PTT-26.4 INR(PT)-1.0 [2151-7-6] 02:27PM BLOOD PT-10.6 PTT-25.8 INR(PT)-1.0 [2151-7-5] 06:00AM BLOOD PT-10.9 PTT-29.1 INR(PT)-1.0 [2151-7-3] 07:45PM BLOOD PT-11.0 PTT-27.1 INR(PT)-1.0 [2151-7-7] 02:37AM BLOOD Glucose-146* UreaN-26* Creat-1.6* Na-137 K-3.8 Cl-101 HCO3-28 AnGap-12 [2151-7-6] 02:27PM BLOOD Glucose-145* UreaN-24* Creat-1.8* Na-140 K-4.0 Cl-102 HCO3-29 AnGap-13 [2151-7-6] 07:35AM BLOOD Glucose-168* UreaN-23* Creat-1.7* Na-139 K-3.9 Cl-102 HCO3-29 AnGap-12 [2151-7-5] 06:00AM BLOOD Glucose-117* UreaN-22* Creat-1.6* Na-140 K-3.3 Cl-102 HCO3-31 AnGap-10 [2151-7-4] 07:30AM BLOOD Glucose-132* UreaN-25* Creat-1.7* Na-140 K-4.7 Cl-103 HCO3-30 AnGap-12 [2151-7-3] 07:45PM BLOOD Glucose-173* UreaN-24* Creat-1.6* Na-137 K-3.2* Cl-101 HCO3-31 AnGap-8 [2151-7-6] 02:27PM BLOOD ALT-17 AST-42* LD(LDH)-272* AlkPhos-99 TotBili-0.4 [2151-7-5] 06:00AM BLOOD ALT-41* AST-48* AlkPhos-104 TotBili-0.5 [2151-7-5] 06:00AM BLOOD ALT-41* AST-48* AlkPhos-104 TotBili-0.5 [2151-7-7] 02:37AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.1 [2151-7-6] 02:27PM BLOOD Calcium-8.4 Phos-3.6 Mg-2.2 [2151-7-6] 07:35AM BLOOD Calcium-8.2* Phos-3.2 Mg-2.0 [2151-7-5] 06:00AM BLOOD Calcium-8.2* Phos-3.6 Mg-1.6 [2151-7-4] 07:30AM BLOOD Calcium-8.0* Phos-3.6 Mg-1.7 [2151-7-3] 07:45PM BLOOD Albumin-3.4* [2151-7-3] 07:45PM BLOOD VitB12-941* [2151-7-6] 02:27PM BLOOD TSH-3.5 [2151-7-3] 07:45PM BLOOD TSH-6.3* [2151-7-6] 05:49PM BLOOD Type-ART pO2-120* pCO2-57* pH-7.37 calTCO2-34* Base XS-6 Intubat-NOT INTUBA [2151-7-6] 11:41AM BLOOD Type-ART pO2-105 pCO2-67* pH-7.27* calTCO2-32* Base XS-1 Intubat-NOT INTUBA [2151-7-6] 11:41AM BLOOD Glucose-156* Lactate-1.2 Na-136 K-3.9 Cl-100 [2151-7-6] 11:41AM BLOOD freeCa-1.16 Brief Hospital Course: 82 y.o. man with a history of COPD, lung cancer s/p lobectomy, MI s/p stenting, diastolic CHF who presented with R hip fracture now POD7 s/p repair who was transferred several times to the MICU for SOB/hypercarbic respiratory failure and eventually developed a high-grade small bowel obstruction for which he was eventually made comfort measures only and extubated. . # Hypercarbic Respiratory Failure / COPD: He was known to have an FEV1 of 26% of expected in [2145]. On POD1, he developed tachypnea, O2 desaturations into the 80s which responded to mask ventilation, and an ABG showing pH 7.27 and pCO2 67 (baseline is in the 50s, reportedly). The original differential for his respiratory failure was broad, including PE, PNA, flash pulmonary edema from diastolic heart failure, and a-fib. PE and pneumonia were ruled-out with a CT-A Chest. Cardiac etiology was possible given that he was intermittently going into a-fib and has a history of CHF. He also did not appear volume overloaded on exam. Atelectasis and lobectomy may have contributed to SOB but does not explain symptoms alone. Pt improved significantly on IV steroids, BIPAP, and nebs in the MICU. He was weaned off of his BIPAP down to 3L NC for O2 requirement by POD2. Solumedrol was transitioned to prednisone 40 mg PO the day following his hypercarbic respiratory failure and he was transferred to the medical floor. He was transferred again to the MICU on the night of [7-8] for desaturations following working with the physical therapy team. He was stabilized in the MICU without intervention and worked with PT here. He was transferred back to the floor again. He was then transferred back to the MICU given worsening respiratory distress likely [2-11] small bowel obstruction (see below) for which he was intubated. On [7-12], given the persistent high-grade bowel obstruction for which the patient and family did not want to pursue further treatment, he was made comfort measures only and extubated terminally on [7-12]. #Small Bowel Obstruction On the floor [7-9], he was noted to have a markedly distended bowel in the setting of not having a bowel movement for several days. An abdominal x-ray [7-9] and follow-up CT scan of the abdomen [7-10] noted marked dilation of the small bowel with a transition point at the RLQ, c/w small bowel obstruction likely due to adhesion. A follow-up CT abdomen on [7-12] found persistent diffuse small bowel dilation w/ transition point in the RLQ. Surgery recommended operative intervention however his family elected to make him comfort measures only after family meeting regarding goals of care, given his poor overall prognosis and high risk for surgery. He was extubated on [7-12] and expired that evening. # Mechanical Fall/R Intertrochanteric Hip Fracture: He was transferred from an OSH overnight [2151-7-3] to [Hospital1 18] for further management of his R hip fracture. CT head [7-3] was performed given the concern for an intracranial process, as he hit his head during his fall, but this was unremarkable. X-rays of the pelvis and femur confirmed that his R hip was broken. He was admitted to the Medicine service for management of his comorbidities while awaiting surgery. He received fixation of his R intertrochanteric hip fracture on [2151-7-5] (Dr. [Last Name (STitle) 1005]. On POD1, his Hct trended down to 19.5, likely in the setting of post-op blood loss/equilibration, which resulted in him receiving 1U of packed RBCs. Orthopedics was following, and they recommended weight bearing of R lower extremity as tolerated, PT, Hct TID, and lovenox for 2 weeks. PT was also following, and they recommended out of bed [Hospital1 ] as appropriated for his respiratory status, moving all extremities as tolerated, and that he will need rehab. His pain was well controlled with standing tylenol, lidoderm patch, oxycodone PRN, and morphine PRN severe pain. . # A-Fib with RVR: CHAD2 = 3. Likely paroxysmal, occured in perioperative setting and he has no history of being diagnosed with a-fib. The decision was to hold off on anticoagulation in the post-op period to determine whether this would resolve. He was continued on his home diltiazem. Due to persistent elevation in his BP, his metoprolol XL was increased to 37.5mg qd. . #History of Non-Small Cell Lung Cancer: He is being followed by an oncologist for his history of lung cancer. Recent PET negative for progression of disease. No action was taken during this hospitalizaton. . #R Exophytic Renal Mass: Partially visualized on Chest CT. No action was taken during this admission. # Diastolic heart failure: EF 65% in [2147] on [Hospital1 18] Echo. CXR [7-6] and CT-A on [7-6] did not show evidence of pulmonary edema in the setting of respiratory failure. He was continued on metroprolol succinate XL 25mg PO daily. His furosemide was held during the admission due to him not appearing volume overloaded on exam and intermittent Cr elevations. # CKD: Baseline from PCP [Name Initial (PRE) ] [2151-5-13] show BUN 27 and Cr 1.47. His Cr was 1.53 on presentation to OSH on [7-3], and it remained stable through [7-7], when it was 1.6. His medications were renally dosed. However, his Cr began to increase, up to 2.1 on [7-12], in the setting of increased burden of illness in developing an SBO along with being intubated. # Coronary artery disease: s/p MI with coronary artery stenting in the [2129]. His furosemide was held given that his volume exam did not reveal that he was overloaded. He was continued on his home simvastatin and metoprolol. . # Leukocytosis: He had a leukocytosis since admission (ranging from 12.9-19.7), but this resolved (WBC 8.7) even in setting of new solumedrol administration by the morning of [7-7]. UCx showed no growth. No other foci of infection were appreciated. This was likely due to a stress response from breaking his hip from his mechanical fall. His WBC then elevated into the 20s, most likely due to the development of his SBO. # Macrocytic anemia: His baseline hematocrit was known to be in the high 20s as of [2151-5-13]. On admission, Hct 27.1. His Hct trended down to 19.5 on POD1, resulting in him receiving 1U packed RBCs since he reached his transfusion threshold of 21 in the post-op setting. His HCT remained stable throughout the rest of his hospitalization. # Prostate cancer and BPH: Stable. These issues were stable throughout his hospitalization. He was continued on tamsulosin, doxazosin, finasteride. # Gout: He did not have any acute flares. His colchicine was held due to his renal issues, but his allopurinol was renally dosed. . # Hypothyroidism: He was continued on his home levothyroxine. . #Hyperlipidemia: He was continued on simvastatin 20mg daily. . # Osteoarthritis: His home celebrex was held in the peri-operative setting for his hip fracture repair. Medications on Admission: * Cefuroxime 500mg daily * Simvastatin 20mg daily * Tamsulosin ER 0.4mg daily * Cardizem 180mg twice daily * Proscar 5mg daily * Celebrex 200mg daily * Furosemide 20mg daily * Cardura 4mg daily * Allopurinol 300mg daily * Serevent 50mcg two puffs twice daily * Atrovent HFA 17mcg 2 puffs four times daily * Azmacort 2 puffs twice daily * Colchicine 0.6mg daily * Toprol XL 25mg daily * Levothyroxine 25mcg daily * Spiriva 18mcg daily Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Right Hip Fracture Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2764] Completed by:[2151-7-13]	[ "427.31", "788.20", "E885.9", "733.00", "733.90", "272.4", "593.9", "403.90", "185", "820.21", "530.19", "600.01", "414.01", "428.0", "V15.82", "261", "715.90", "244.9", "288.60", "560.81", "V10.11", "785.6", "428.32", "274.9", "585.3", "V12.54", "491.21", "E944.4", "285.9", "564.00", "584.5", "412", "518.52", "783.7", "530.85", "V45.82" ]	icd9cm	[ [ [] ] ]	[ "38.91", "87.41", "93.90", "79.15", "96.04", "96.07", "96.71" ]	icd9pcs	[ [ [] ] ]	13823, 13832	6371, 13306	308, 406	13894, 13903	3370, 6348	13959, 14089	2413, 2465		13791, 13800		13853, 13873		13332, 13768				13927, 13936													2480, 3351																										238, 270							434, 1490																	1512, 2188	2204, 2397
27,413	144,707	33609	Discharge summary	report	Admission Date: [2197-2-12] Discharge Date: [2197-2-13] Date of Birth: [2171-3-6] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2962] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 77867] is a 25 year old male with 4 year history of chest pain and 3 prior episodes of syncope who is transferred to [Hospital1 18] for further evaluation of syncope in the setting of a 13 second pause on telemetry. Three years ago the patient began having episodes of intermittent left sided chest pressure occasionally radiating to his back. He denies any precipitating, exacerbating, or alleviating factors. It is not associated with exertion; does not improve/worsen with positional changes. It occurs 1x/month lasting two hours each time. The chest pain is associated with shortness of breath. He denies any associated nausea, diaphoresis, arm or jaw radiation. He reportedly had a negative work up for the chest pain 1.5 years ago at [Hospital1 1774]. He reports history of an MRI, CT and EKG which were all negative/unrevealing. He does not recall if an echocardiogram or stress test was done. He underwent cholecystectomy 1.5 years ago as his chest pain was attributed to referred gallbladder pain. This did not improve his symptoms. He was also prescribed Protonix which he did not ever take regularly. . Approximately one and one half years ago he presented to an OSH complaining of the above chest pain. Work up again was negative and he was discharged to home. As he was walking out of the ED he syncopized with no preceding symptoms. He returned to the ED with chest pain days later. This time while lying on the hospital bed, he remembers waking up with multiple hospital personnel around him. He had syncopized reportedly in the context of an 11 second pause. He reportedly had no stigmata of seizures (tounge biting, loss of bladder or bowl function etc). Upon discharge he wore a 24 hr holter monitor which was unrevealing. . Finally, this morning at 330 am he developed left sided chest pressure. He presented to the ED at [Hospital3 ]. Prior to presenting to the ED he had been out drinking, [4-11] drinks. While in the ED, lying in bed, nurse [First Name (Titles) ] [Last Name (Titles) 77868] IV protonix. He had a syncopal event that was accompanied by a 13 second pause. This time patient was able to sense it coming; he felt "[Doctor Last Name 352]" and "blurry" for approximately 5 seconds prior. He denies seeing needles, blood etc prior. The strip of the event accompanying the patient is notable for a gradually prolonged P-P interval. Also of note, K at OSH was 3.0. CXR negative. He received 2L IVF, IV protonix. . On arrival to [Hospital1 18] CCU he is sitting up in bed. He has no complaints. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for chest pain and "labored breathing" as above. Syncope and presyncope as above. He experiences occasional palpitations which are not associated with episodes of chest pain. Denies dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema. Past Medical History: s/p Cholecystectomy, [2194] Social History: The patient 4 alcoholic drinks 3x/week. He states he does not use any other substances but did try coke 3 years ago. He smokes 1ppd x 7 years. Family History: There is no family history of premature coronary artery disease, sudden death or HCM. His father had an MI at age 55, mother is healthy. He has three healthy sisters. [Name (NI) 9876] with MI at age 47, died of 5th MI. PGM with MI in 40s. No family history of arrhythmias. Physical Exam: VS: T AF, BP 129/78, HR 66, RR 15, O2 99%onRA Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 7cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: [2197-2-12] 07:19PM BLOOD WBC-7.3 RBC-4.72 Hgb-14.2 Hct-40.0 MCV-85 MCH-30.0 MCHC-35.4* RDW-12.8 Plt Ct-251 [2197-2-13] 04:59AM BLOOD WBC-7.3 RBC-4.59* Hgb-13.8* Hct-39.9* MCV-87 MCH-30.0 MCHC-34.5 RDW-12.9 Plt Ct-240 [2197-2-12] 07:19PM BLOOD Plt Ct-251 [2197-2-12] 07:19PM BLOOD Glucose-86 UreaN-4* Creat-0.8 Na-143 K-3.9 Cl-107 HCO3-27 AnGap-13 [2197-2-12] 07:19PM BLOOD ALT-34 AST-43* LD(LDH)-165 CK(CPK)-158 AlkPhos-61 TotBili-0.5 [2197-2-13] 04:59AM BLOOD CK(CPK)-113 [2197-2-12] 07:19PM BLOOD CK-MB-3 cTropnT-<0.01 [2197-2-13] 04:59AM BLOOD CK-MB-2 cTropnT-<0.01 [2197-2-12] 07:19PM BLOOD Albumin-4.4 Calcium-9.1 Phos-2.7 Mg-1.8 CXR: Heart size and pulmonary vascularity are normal. Lungs and pleural surfaces are clear. IMPRESSION: Normal heart size and clear lungs. TTE: The left atrial volume is increased. 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). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). There is no left ventricular outflow obstruction at rest or with Valsalva. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild left atrial dilation. No structural cardiac cause of syncope identified Exercise-MIBI: Left ventricular cavity size is normal. Resting and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 56%. There is no prior for comparison. IMPRESSION: Normal myocardial perfusion study. LVEF 56%. 25 year old man with a h/o syncope associated with chest pain (captured 13 second pause on telemetry). The patient exercised for 15 minutes on [Initials (NamePattern4) ] [Last Name (NamePattern4) ] protocol and stopped for fatigue. The estimated peak MET capacity was 15 which represents an excellent exercise tolerance for his age. The patient denied any arm, neck, back, or chest discomfort throughout the procedure. No significant EKG changes noted during exercise or recovery. However, a more prominent rsR' was noted in leads V2 (? clinical significance). The rhythm was sinus with rare isolated VPBs. The hemodynamic response to exercise was appropriate. IMPRESSION: Excellent exercise tolerance. No anginal type symptoms or EKG changes from baseline. No exercise-induced brady- or tachyarrhythmias. Nuclear report sent separately. Brief Hospital Course: Chest pain: The patient was ruled out for ACS with a normal ECG and 2 sets of negative cardiac biomarkers. He was chest pain free for the duration of his admission. He was continuously monitored on telemetry with no events. He underwent an exercise-MIBI which did not reproduce his symptoms of chest pain. Furthermore the nuclear images showed no defects, making it very unlikely that his chest pain is cardiac in nature. He will follow up with his PCP for further work up. Syncope: The patient was monitored continuously on telemetry with no events. His heart rate responded appropriately to stimulation, making sick sinus very unlikely. He had no signs of long QT or Brugada on ECG. A TTE showed a structurally normal heart and a stress-MIBI showed excellent exercise tolerance and no perfusion defects. On examination, he showed signs of increased vagal tone with a strong response to vagal maneuvers causing relative bradycardia and then a reflex tachycardia. It was felt, in conjunction with the EP service, that his episodes of syncope were vaso-vagal in nature. He was advised to remain hydrated and consider compression stockings. He will follow up with his PCP. Medications on Admission: None Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: Vaso-vagal syncope Discharge Condition: All vital signs stable, chest pain free, ambulatory. Discharge Instructions: You were admitted for chest pain and feinting. A nuclear stress test was done on your heart which did not cause similar symptoms. An echocardiogram (ultrasound) of your heart showed no structural abnormalities. It is likely that your chest pain was not caused by your heart. Your feinting is likely the result of vaso-vagal causes, which is classic feinting from your heart slowing down and blood pooling in your legs. This can be caused by a number of things including: standing up too fast, being too hot, standing for prolonged periods of time, increased stress, the sight of needles or blood. You should make sure to keep hydrated throughout the day to prevent this from happening again. Please call your doctor or return to the emergency room if you experience chest pain, shortness of breath, further feinting episodes, fevers, chills or any other symptom that concerns you. Please make your follow up appointments as instructed. Followup Instructions: Please call Dr.[Name (NI) 6767] office at [Telephone/Fax (1) 22224] to schedule a follow up appointment in the next 2-4 weeks. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2964] MD, [MD Number(3) 2965]	[ "786.59", "780.2" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	9124, 9130	7867, 9040	282, 289	9193, 9248	4936, 7844	10236, 10503	3811, 4095		9095, 9101		9151, 9172		9066, 9072				9272, 10213													4110, 4917																										232, 244							317, 3578																	3600, 3633	3649, 3795
11,486	149,066	48457	Discharge summary	report	Admission Date: [2198-4-6] Discharge Date: [2198-4-13] Date of Birth: [2133-2-22] Sex: M Service: MEDICINE Allergies: Penicillins / Adhesive Tape Attending:[First Name3 (LF) 2817] Chief Complaint: tachypnea and mental status changes Major Surgical or Invasive Procedure: none History of Present Illness: 65 yo man with CHF, DVT, ESRD on HD, metastatic poorly differentiated CA, likely NSLCA recently discharged [4-5] after hospitalization for cauda equina syndrome treated with XRT. This afternoon, noted to be very tachycardic and tachypnic en route to [Hospital3 2558] after HD, so EMS brought pt to ED. . In the ED, he was given 750mg iv levofloxacin for possible LLL airspace disease, though progression of metastatic malignancy more likely and CT chest did not show consolidation. Past Medical History: #. Onc HX: [12-11] pre-renal transplant CT scan chest noted enlarged RML nodule, w/ subcentimeter FDG avid scattered lymph nodes. Developed neck pain and found to have C2 pathological fracture, [11-22] cytology demonstrated poorly differentiated carcinoma. Likely non-small cell lung carcinoma, with RML mass and metastasis to the cervical and sacral spine. The only manifestation of his disease currently is cervical neck pain, s/p pathologic fracture and posterior cervical arthrodesis C1-C3 and palliative XRT. #. Left Common Femoral DVT: small non-occlusive, possibly chronic DVT and started on coumadin for a goal INR [1-7] in [1-/2198] #. CAD s/p angioplasty D1 [7-10] and stents to OM2/3 in [3-11] #. ESRD secondary to FSGS on HD (MWF) #. Hypertension #. LLE peroneal nerve palsy [1-6] GSW to L leg #. Thalassemia trait #. h/o Substance abuse (heroin/cocaine); reports none since [2163] #. CHF w/ EF 35% in [11-11], EF 25-30% on [Date Range 113] [2198-1-23] #. MR - 2+ on [Month/Day/Year 113] in [11-11]; now found to be 3+ MR [First Name (Titles) ] [Last Name (Titles) 113] #. Pathological C2 Fx s/p C1-3 Fusion #. Parotiditis - [12-12] (levo/flagyl) #. CDiff - [12-12] #. HCV - grade 1 inflammation and stage 0 fibrosis on bx [2-9] Social History: He lives with his partner but they are not legally married, has 2 sons. Used to work in construction, + smoker 1 PPD for many years quit recently, rare ETOH, no drugs. Recently has been living in rehab. Family History: Brother with CAD, and kidney disease requiring hemodialysis Physical Exam: GEN: obese, lethargic male HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection, anicteric, OP clear, MMM, Neck supple, no LAD, no carotid bruits CV: RRR, nl s1, s2, no m/r/g PULM: CTAB, no w/r/r with good air movement throughout ABD: soft, NT, ND, + BS, no HSM EXT: warm, dry, +2 distal pulses BL, no femoral bruits NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis PSYCH: appropriate affect Pertinent Results: [2198-4-6] 09:38PM WBC-22.3* RBC-3.01* HGB-7.6* HCT-23.9* MCV-80* MCH-25.3* MCHC-31.9 RDW-20.4* [2198-4-6] 09:38PM NEUTS-95.6* BANDS-0 LYMPHS-1.0* MONOS-2.0 EOS-1.3 BASOS-0 [2198-4-6] 09:38PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-2+ MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-OCCASIONAL OVALOCYT-1+ TARGET-1+ TEARDROP-OCCASIONAL [2198-4-6] 09:38PM PLT SMR-NORMAL PLT COUNT-292 [2198-4-6] 09:38PM PT-44.9* PTT-35.3* INR(PT)-5.0* [2198-4-6] 09:38PM CK-MB-NotDone cTropnT-0.45* [2198-4-6] 09:38PM CK(CPK)-28* [2198-4-6] 09:38PM GLUCOSE-80 UREA N-33* CREAT-1.8# SODIUM-140 POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-31 ANION GAP-15 CXR: Multifocal bilateral parenchymal opacities are similar in appearance to previous studies, although there is slightly increased opacity seen at the left base. Most likely, these represent the patient's known bilateral metastatic disease, though it is difficult to exclude an underlying pneumonia at the left base. There is no significant pleural effusion. There is no pneumothorax. Left basilar atelectasis is slightly improved. CTA Chest: IMPRESSION: 1. No pulmonary embolism. No aortic dissection. 2. Unchanged appearance of innumerable bilateral spiculated pulmonary nodules, most consistent with metastatic disease. 3. Unchanged appearance of low-attenuation foci within the liver, which may represent metastatic disease. 4. Unchanged appearance of multiple osseous metastatic lesions. CT Head: IMPRESSION: No enhancing mass lesions. Stable head CT examination relative to [2198-1-21] with no acute intracranial process. Brief Hospital Course: A/P: 65 yo M with metastatic poorly differentiated CA which likely NSLCA, CHF, DVT, ESRD on HD, recent cauda equina syndrome treated with xrt and dexamethasone discharged [4-5] returned [4-6] with hypotension, mental status change. No specific etiology was identified for his deterioration, which was likely multifactorial due to his widely metastatic cancer and multiple medical co-morbitities. The patient, in his more lucid moments, was clear that he did not want to return to rehab and would prefer to go home with hospice care; however, owing to a complex social situation at home and his family's different opinions of whether they would be able to keep him comfortable at home, this was not considered feasible. While ongoing discussions with his partner, his two sons, and various members of his extended family about possible disposition plans that would allow him to leave the hospital without returning to an extended care facility were underway, the patient continued to worsen in terms of mental status and respiratory status. His multifactorial hypotension precluded intermittent HD, so this was discontinued. His respitory status particularly worsened, with several likely aspiration events and additionally several episodic oxygen desaturations unrelated to obvious aspiration. Since he had indicated his wish for hospice care, and the palliative care team was following, he was not intubated for this respiratory distress. His family was called and advised to come to his bedside. He expired on [2198-4-13]. Medications on Admission: Clopidogrel 75 mg PO DAILY Simvastatin 20 mg PO DAILY Gabapentin 300 mg PO QHD B Complex-Vitamin C-Folic Acid 1 mg PO DAILY Sevelamer HCl 1600 mg PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Acetaminophen 500 mg PO Q6H 7Docusate Sodium 100 mg PO BID Lisinopril 10 mg PO DAILY Fentanyl 50 mcg/hr Patch 72 hr Transdermal Q72H Polyethylene Glycol 3350 17 gram (100 %) PO once a day. Aspirin 162 mg PO DAILY Metoprolol Succinate 12.5 mg PO DAILY Omeprazole 20 mg PO once a day. Fentanyl Citrate (PF) 50 mcg/mL Solution Sig: Twenty Five (25) mcg Injection q2 hours as needed for pain. Dexamethasone 0.5 mg Tablet Sig: Taper as follows PO every six (6) hours: 2mg PO q6hr for 3 days, then 1mg PO q6hr for 3 days, then 0.5mg PO q6hr for 3 days, and then discontinue. Discharge Medications: n/a Discharge Disposition: Home With Service Facility: hospice of [Location (un) 86] and greater [Hospital1 *] area Discharge Diagnosis: poorly differentiated metastatic cancer end-stage renal disease coronary artery disease Discharge Condition: expired Discharge Instructions: N/a Followup Instructions: n/a	[ "786.06", "486", "492.8", "427.31", "414.01", "285.21", "428.0", "786.50", "162.4", "276.3", "198.5", "785.0", "403.91", "585.6", "428.22", "V58.61", "V12.51" ]	icd9cm	[ [ [] ] ]	[ "39.95", "99.04" ]	icd9pcs	[ [ [] ] ]	7005, 7103	4627, 6167	323, 330	7235, 7245	3004, 4463	7297, 7304	2425, 2486		6977, 6982		7124, 7214		6193, 6954				7269, 7274													2501, 2985																										248, 285							358, 850			4472, 4604														872, 2189	2205, 2409
27,586	138,041	34469	Discharge summary	report	Admission Date: [2115-6-19] Discharge Date: [2115-6-28] Date of Birth: [2064-4-29] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 552] Chief Complaint: mental status change Major Surgical or Invasive Procedure: 1.Lumbar puncture [2115-6-20] 2.CT Head w/, w/o contrast, C/L spine [6-20] 3.CT head w/o constrast [6-22] 4.MR [Name13 (STitle) 430]/Brain [6-22] 5.EEG [6-21], [6-22] 6.PICC line placement [6-24] History of Present Illness: 51 y/o woman with no known past medical history presenting as transfer from [Hospital3 10310] Hospital where she presented with fever, headache, altered mental status and was found to have a CSF with 300 WBCs, 93% lymphs, 320 protein, glucose 34. . Her family reports that her problems began 3 weeks ago when she was diagnosed with Sinusitis. She was treated with amoxacillin. She then developed acute low back pain for which she presented to the ED [Hospital3 ] prior to admission. She was alert and oriented at that time, and it was felt an acute muscle spasm when lifting her cat. She also had continued sinusitis symptoms and was given a Zpack and discharged home. She was given flexaril and vicodin for her back pain. . She began to be confused on monday evening. Her boyfriend notes that she was very tired and went to bed early monday night. He tried calling her tuesday but she never answered his calls. Her daughters report that she was sleep walking, rambling, and confused. She was brought to the OSH ED and admitted . Her OSH hospital course is notable for broad empiric therapy with Vanc/CTX/Ampicillin/Acyclovir all at meningeal doses. She was seen by Infectious disease. She was also given steroids. She was then transferred to [Hospital1 18] for further care. Here she had a seizure on the floor and was transferred to ICU where she was intubated for airway protection. Repeat Head CT/MRI/LP eventually showed HSV 2 encephalitis. ID & Neuro followed the pt. Pt's rocephin was discontinued on [6-23] and continued on acyclovir. For seizures, pt placed on dilantin. Pt also noted to have anisocoria and per neuro, no obvious intracranial process as [Last Name (LF) 79218], [First Name3 (LF) ] ophtho consulted by ICU team. Pt came out of ICU on [6-25]. Pt is more alert per boyfriend. She is still confused, but is getting better everyday. She denies headache, photo-phonophobia Past Medical History: none Social History: has had boyfriend x 16 years. Lives with 2 daughters. [2-1] etoh beverages/week, allthough she may go 1 month without drinking. SMokes [11-28] pk/day. Denies IVDU or other drug use, but family was concerned about prior IVDU . Family History: Noncontributory Physical Exam: Vitals: Tm 98.2, P 74-81, BP 136-150/80-90, RR 18-20, 94-97%RA GEN NAD EYE Anicteric, L>R pupil equally reactive to light ENT Moist OP Neck: supple CV RRR RESP CTA ant GI SNT NABS GU no CVAT MSK Warm, no edema SKIN No rash NEURO oriented to self, year, month, day,date, knows she is in [Hospital1 ], CN intact, motor/sensation non-focal PSYCH Calm HEME/[Last Name (un) ] no LN ACCESS L PICC Pertinent Results: [2115-6-21] 06:25AM BLOOD WBC-4.1 RBC-4.61 Hgb-13.7 Hct-38.7 MCV-84 MCH-29.8 MCHC-35.5* RDW-11.9 Plt Ct-129* [2115-6-20] 01:00AM BLOOD WBC-3.1* RBC-4.47 Hgb-13.7 Hct-37.5 MCV-84 MCH-30.6 MCHC-36.5* RDW-12.0 Plt Ct-117* [2115-6-20] 01:00AM BLOOD Plt Ct-117* [2115-6-21] 06:25AM BLOOD Plt Ct-129* [2115-6-20] 01:53PM BLOOD WBC-3.1* Lymph-14* Abs [Last Name (un) ]-434 CD3%-45 Abs CD3-197* CD4%-31 Abs CD4-133* CD8%-14 Abs CD8-63* CD4/CD8-2.1 [2115-6-20] 01:00AM BLOOD Glucose-115* UreaN-16 Creat-0.6 Na-140 K-3.5 Cl-106 HCO3-24 AnGap-14 [2115-6-21] 06:25AM BLOOD ALT-19 AST-21 [2115-6-20] 01:00AM BLOOD ALT-16 AST-23 LD(LDH)-202 CK(CPK)-125 AlkPhos-33* TotBili-0.3 [2115-6-21] 06:25AM BLOOD Calcium-8.6 Phos-2.5* Mg-1.9 [2115-6-20] 01:00AM BLOOD Calcium-8.6 Phos-2.0* Mg-2.0 [2115-6-20] 01:00AM BLOOD TSH-0.093* [2115-6-20] 01:00AM BLOOD Free T4-1.0 [2115-6-20] 01:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2115-6-20] 06:44PM CEREBROSPINAL FLUID (CSF) WBC-480 RBC-70* Polys-4 Lymphs-83 Monos-10 Other-3 [2115-6-20] 06:44PM CEREBROSPINAL FLUID (CSF) WBC-400 RBC-100* Polys-6 Lymphs-76 Monos-16 Other-2 . CT Head [2115-6-20]:IMPRESSION: No hemorrhage or mass effect. . CT C Spine [2115-6-20]: IMPRESSION: 1. No fracture or abnormal alignment. 2. Multilevel degenerative changes of the cervical spine as outlined above. . CT L Spine [2115-6-20]: MPRESSION: Unremarkable CT of the lumbar spine. Brief Hospital Course: Assessment/Plan: This is a 51 yo female with no known PMH presenting as transfer from OSH with acute meningoencephalitis. . 1. Meningioencephalitis: The patient was admitted with CSF findings from OSH most c/w viral meningitis. Her CSF from OSH showed:WBC of 430 with 95% lymphocytes, glucose 34, 190 RBC, protein 340. She was initially continued on CTX, acyclovir, decadron, amp, and vanc the night of admission. Infectious disease was consulted the morning after admission, and recommended tailoring her regimen down to only acyclovir and ceftriaxone. Repeat LP was performed on [2115-6-20] and showed showed WBC 480 with 83% lymphs, glucose 65, protein 225, RBC 70. Here, Head CT and CT C spine/L spine were negative for abscess (done due to complaints of neck/back pain). LP here was sent for enterovirus PCR, lyme serologies, West Nile Virus, HSV PCR, viral culture, bacterial culture, fungal culture. Blood studies for CMV, EBV, RPR, and Lyme were neg. On [6-21], pt was found to be in increasingly agitated and disoriented, and eventually progressed to status epilepticus, with persistent rightward eye deviation and foamy emesis but no tonic-clonic movements. She was treated with hydralazine 10 mg IV x 1, 1 amp D50, ativan 1 mg IV x 4, valium 7 mg IV x 1. Oxygenation was preserved on NRBM. She was transferred to the ICU for further observation and management. In the unit, pt was maintained on Dilantin with no new seizure activity. Pt was intubated only for MRI/MRA, with prompt extubation. Test results finally showed HSV 2 PCR with 605,000 DNA copies. Pt was continued on Acyclovir, and Ceftriaxone was discontinued [6-23]. Mental status gradually improved, and pt was was transferred back to the floor [6-24]. On the floor she continued to do well, was confused but improving daily. Per ID recs, pt to be continued on Acyclovir 700mg IV Q8 until [7-14]. She had a L picc placed for this. Neuro recommended continuing Dilantin 100mg TID. She will be seen in both ID and Neuro [Month/Year (2) ] for follow up. 2. Anisocoria - Per neuro, no findings to explain the anisocoria. Seen by ophtho and could not do a full exam, so recommend setting up w outpt fu. Ophtho note faxed to [Hospital ] [Hospital ], cannot give appt now but they will call pt and make appt 3. Leukopenia/thrombocytopenia - CD4 count low but HIV Ab neg. HIV PCR pending. CD 4 count can be low in setting of any acute viral infection and may be [12-29] to HSV infefction 4. HTN - pts sbp in 120-160 range, pt started on amlodipine, will need to FU w PCP 5. Abnomral thyroid function- Initially TSH low w nl FT4 in setting of acute illness, repeat labs wnl. PCP can recheck [Name9 (PRE) ] and if concern for subclinical hyperthyroidism, pt can be referred to endocrinology PT IS BEING DISCHARGED [Hospital ] REHAB IN [Hospital1 420], MA. Medications on Admission: Hydrocodone/APAP 5/500 - had taken 9 over the last three days Cyclobenzaprine prn Discharge Medications: 1. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO three times a day. Tablet, Chewable(s) 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Acyclovir 700 mg IV Q8H Discharge Disposition: Extended Care Facility: [Location (un) 6594] [Hospital1 ] Discharge Diagnosis: HSV 2 Encephalitis Seizures, most likely [12-29] to HSV encephalitis HTN Leukopenia and Thrombocytopenia- etiology unclear Discharge Condition: Good Discharge Instructions: You were seen for a meningitis. You had a CT scan of your head, neck, and back which showed no abscess. You had a repeat lumbar puncture while you were here which showed meningitis findings. The tests eventually showed HSV 2, a virus, as the cause of the meningitis. Your episode of seizure was most likely from that but the neurologists want you to continue taking phenytoin and they will see you in [Month/Day (2) ]. You will also complete a course of antivirals and be seen by Infectious disease doctors [First Name (Titles) ] [Last Name (Titles) ]. You were also noted to have unequal pupils. No cause was found on the Imaging studies of your brain. An eye doctor saw you in the hospital but could not do a full exam. They recommended that you be seen in clninc. We have made you an appt to be seen in Eye [Last Name (Titles) ], see below Call your doctor or return to the ER for: fever, confusion, shortness of breath, chest pain, seizures, new weakness or numbness of any of your arms or legs or severe headaches, sensitivity to sound/light Followup Instructions: 1. ID appointment on [Last Name (LF) 2974], [7-5] at 2:30 pm in Urgent [Hospital ] [Hospital ] at [Doctor First Name ] [Hospital ] medical building.ph [Telephone/Fax (1) 457] 2. Provider: [First Name4 (NamePattern1) 8495] [Last Name (NamePattern1) 8496], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2115-7-18] 11:30 3. Provider: [Name Initial (NameIs) 1220]. [Name5 (PTitle) 162] & [Doctor Last Name ] Phone:[Telephone/Fax (1) 44] Date/Time:[2115-8-12] 4:00. Neurology appointment 4.Dr. [Last Name (STitle) 78055] [Name (STitle) 78054] [State 68225], [Location (un) 14663], [Numeric Identifier 73009]. ph [Telephone/Fax (1) 79219]. Please call and make appt for hospital followup in [12-31] weeks 5. Eye appt. Provider: [Name10 (NameIs) 6131] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 253] Date/Time:[2115-7-12] 1:30	[ "276.8", "041.19", "305.1", "348.39", "473.9", "242.90", "345.3", "276.52", "054.3", "599.0", "288.50", "287.5", "366.9", "401.9", "379.41" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71", "38.93", "03.31" ]	icd9pcs	[ [ [] ] ]	8160, 8228	4795, 7670	335, 564	8399, 8406	3263, 4772	9519, 10457	2811, 2828		7802, 8137		8249, 8378		7696, 7779				8430, 9496													2843, 3244																										275, 297							592, 2516																	2538, 2544	2560, 2795
9,799	146,020	29790	Discharge summary	report	Admission Date: [2115-2-7] Discharge Date: [2115-2-12] Date of Birth: [2044-8-25] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: 70yo man direct admission to operating room for coronary bypass surgery. Had cardiac catheterization [1-28], referred to ct surgery after catheterization Major Surgical or Invasive Procedure: CABGx 4(LIMA-LAD, SVG-OM, SVG-PDA-PLV)[2-7] History of Present Illness: 70 yo man history of ^chol, PVD, HTN, DM had +ETT then referred for cardiac cath which revealed 3VD with preserved EF 60%. Referred for bypass grafting after cardiac cath Past Medical History: ^chol PVD COPD GERD Pulmonic stenosis DM HTN Social History: Lives with wife, Retired. +tobacco [12-25] pack per day x 55 years. ETOH 5-6 beers/week Family History: noncontributory Physical Exam: Admission VS HR 83 BP 183/77 RR 20 Ht 5'9" Wt 183lbs Gen NAD Neuro grossly intact Neck supple, no bruits Pulm CTA bilat CV RRR, no murmur Abdm soft, ND/NT/NABS Ext warm, well perfused. no edema or varicosities. Pulses 2+ throughout Discharge VS T 99.8 HR 94SR BP 158/62 RR 20 O2sat 93%RA Gen NAD Pulm CTA bilat CV RRR S1-S2. Sternum stable, incision CDI Abdm soft, NT/ND/NABS Ext no edema, left leg SVH site w/steris CDI Pertinent Results: [2115-2-7] 12:57PM WBC-10.1 RBC-3.14# HGB-10.1# HCT-28.3# MCV-90 MCH-32.3 MCHC-35.8* RDW-14.1 [2115-2-7] 12:57PM PLT COUNT-141* [2115-2-7] 12:57PM PT-14.3* PTT-37.4* INR(PT)-1.3* [2115-2-7] 07:36AM GLUCOSE-111* NA+-139 K+-4.0 [2115-2-7] 12:57PM UREA N-9 CREAT-0.7 CHLORIDE-114* TOTAL CO2-25 [2115-2-12] 09:33AM BLOOD WBC-7.1 RBC-3.01* Hgb-9.5* Hct-27.2* MCV-90 MCH-31.7 MCHC-35.1* RDW-14.2 Plt Ct-200# [2115-2-10] 03:19AM BLOOD PT-12.4 PTT-32.2 INR(PT)-1.1 [2115-2-12] 09:33AM BLOOD Glucose-201* UreaN-18 Creat-0.9 Na-137 K-3.9 Cl-101 HCO3-31 AnGap-9 RADIOLOGY Final Report CHEST PORT. LINE PLACEMENT [2115-2-9] 2:14 PM CHEST PORT. LINE PLACEMENT Reason: position of central line [Hospital 93] MEDICAL CONDITION: 70 year old man with s/p CABG after central line placement REASON FOR THIS EXAMINATION: position of central line HISTORY: CABG, central line placement. Assess central line. CHEST, SINGLE AP VIEW. A right IJ central line is present, replacing the previously identified right IJ sheath. The tip overlies the mid/lower SVC. No pneumothorax is identified on this lordotic film. The patient is status post sternotomy, with a prominent but stable cardiomediastinal silhouette. There is no CHF. There is subsegmental atelectasis at the left base, possibly with very slight blunting of the costophrenic angle, but this is all stable. No right-sided infiltrate or effusion is identified. Minimal atelectasis at the right cardiophrenic angle is noted. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 4343] Approved: SUN [2115-2-10] 7:29 PM Brief Hospital Course: Mr [Known lastname ] was a direct admission to the operating room for coronary artery bypass grafting. please see OR report for details, in summary he had CABGX4 with LIMA-LAD, SVG-OM, SVG-PDA with Ygraft to PLV. His bypass time was 84 minutes and Xclamp time was 68 minutes. The patient tolerated operation well and was transferred from the OR to cardiac surgery ICU. He did well in the immediate post-op period. His anesthesia was reversed, he was weaned from ventilator and sucessfully extubated. On POD1 the patient remained hemodynamically stable and was begun on Bblockers and diuretics. On pOD2 the pt was transferred to the step down floors and over the next several days his activity level was advanced until on POD 5 it was decided he was stable and ready for discharge to home with visiting nurses. Medications on Admission: Humulin 70/30 36units QAM and 26 units QPM Neurontin 300TID Metformin 500QD ASA 325 QD Plavix 75 QD Advair 100/50 2puff [Hospital1 ] Toprol XL 25 QD Prilosec 20QD Lisinopril 20QD Lipitor 20 QD NTG sl/prn Discharge Medications: 1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 2 weeks. Disp:28 Capsule, Sustained Release(s) Refills:0 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:270 Tablet(s) Refills:2 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 10. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension Sig: 36unitsQAM/26unitsQPM Subcutaneous twice a day. 11. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day for 2 weeks. Disp:42 Tablet(s) Refills:0 12. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: [12-25] Inhalation twice a day. 13. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily) for 4 weeks. Disp:30 Patch 24HR(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 ] vna Discharge Diagnosis: CAD s/p CABGx4(LIMA-LAD,SVG-OM,SVG-PDA-PLV)[2-7] ^chol PVD COPD GERD Pulmonic stenosis DM HTN Discharge Condition: good Discharge Instructions: keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medications as prescribed. Call for any fever, redness or drainage from wounds Followup Instructions: wound clinic in 2 weeks Dr [Last Name (STitle) ] [Last Name (STitle) ] [2-24] weeks Dr [Last Name (STitle) ] in 4 weeks Completed by:[2115-2-12]	[ "250.00", "530.81", "414.01", "272.0", "496", "443.9", "427.31", "401.9" ]	icd9cm	[ [ [] ] ]	[ "36.13", "39.61", "36.15" ]	icd9pcs	[ [ [] ] ]	5669, 5720	3084, 3899	478, 527	5862, 5869	1403, 2136	6071, 6238	921, 938		4158, 5646	2173, 2232	5741, 5841		3925, 4135				5893, 6048													953, 1384																										281, 440	2261, 3061						555, 728																	750, 796	812, 905
25,833	177,746	13041	Discharge summary	report	Admission Date: [2154-5-12] Discharge Date: [2154-5-18] Date of Birth: [2077-1-4] Sex: M Service: MEDICINE Allergies: Aspirin Attending:[First Name3 (LF) 1666] Chief Complaint: Transfered for ERCP for elevated Bilirubin and concern for cholangitis Major Surgical or Invasive Procedure: ERCP History of Present Illness: 77 yo M with h/o HTN, PAF p/w N/V/abdominal pain and poor PO intake to an OSH, who was found to have elevated LFTs and transferred here for ERCP. He initially developed N/V (no hematemesis) about 1 week ago with associated abdominal pain from the wretching, and thought that this was secondary to gastroenteritis. The next few days he had poor PO intake. He went to see his [Name8 (MD) 6435] NP and was treated with belladonna and a medication that he can't remember with some improvement. However, his symptoms returned and he felt progressively weaker, culminating in a fall at home from his bed with head injury, but no LOC. After the fall, he was unable to get help for 5 hours before contacting his daughter and being brought into the hospital. He presented to the ED at [Location (un) ] on [5-11] where he was found to be hypotensive with elevated LFTs and CK and a temp to 101. He was also found to have ARF with a Cr 2.4 which improved to 1.6 with hydration, and a leukocytosis of 13.4. He was noted to have some small lacerations on his face in the ER, which were stitched up, and had a head CT which was negative for acute intracranial abnormality. His admission cardiac enzymes were CK 9000, MB 51 and troponin 0.1 (negative). The troponin remained flat, and his other enzymes normalized with hydration to CK 3700, MB 13. His LFTs on admission included an AST 175 (peak 231), ALT 85, Bili 12.8 (peak 14.8). Lipase and amylase were 181 and 186, respectively, about 1.3 times normal. An ammonia level was normal. An abdominal ultrasound showed a normal sized GB, intrahepatic and extrahepatic biliary ductal dilatation, a dilated CBD measuring 1.0 cm, + sludge, a limited evaluation of the pancreas and no visualized stones. A CXR showed a large hiatal hernia witha associated LLL atelectasis. A chest CT was ordered for further evaluation and showed a large hiatal hernia extending to both hemithoraces with associated adjacent atelectasis, without infiltrate or pleural effusion seen. While in the ED, he developed an episode of SVT with associated SOB and wheezing and that resolved on its own. The patient was admitted to the MICU for monitoring and hydration. In the MICU, he was started on levophed which was titrated off early in the AM, unasyn 3 g Q6. His CVP was 17-18. He became wheezy later that AM with a desaturation to 70% and his O2 was increased from 2LNC to a 100% FM. He was found to be in AF with RVR with rate 150, and a CXR showing pulmonary edema. He was given lopressor, SL NTG, 40 mg IV lasix. His BP became unsteady, and he was given an IV bolus with no effect and started on a neosynephrine drip. An ABG was 7.23/36/156/14.7/98.7, and his IVF were changed to D5 with 3 Amps HCO3 at 150 cc/hr. A repeat ABG was 7.38/30.4/256/17.7. The patient's antibiotics were also switched to gentamicin, unasyn Q6 and levaquin just prior to transfer. GI was consulted during his evaluation, and recommended an MRCP. As an MRCP was not possible given the patient's multiple pumps, the decision was made to transfer the patient to [Hospital1 18] for consideration of ERCP and for tertiary care. Just prior to transfer, the patient had another episode of flash pulmonary edema, and was given a total of 15 mg lopressor without benefit, 10 mg diltiazem with control of his rate, placed on a diltiazem drip, SL NTG x1 and 1 mg of morphine. . ROS: He reports low grade fevers at home to 99-100, no further nausea, vomiting or abdominal pain, no diarrhea (though stools are slightly loose), last BM yesterday, no black or bloody stools, no chest pain, sob, dysuria. Past Medical History: HTN PAF - on anticoagulation and rate control therapy in-situ skin carcinomas, none metastatic, s/p multiple excisions TTE 2 years ago - EF 65% with trace MR [First Name (Titles) ] [Last Name (Titles) ] cancer in remission gout s/p L CEA s/p hernia repair Social History: SH: The patient lives alone in an apartment. Denies current use of cigarettes - quit 50 years ago, 15 year smoking history. He drinks alcohol very occasionally. He is retired, but does work for a car dealer. Family History: FH: noncontributory Physical Exam: On admission to [Hospital Unit Name 153] T 97.8 P 99 BP 119/80 RR 28 98% on 100% NRB Gen: WDWN man lying in bed in NAD HEENT: PERRLA, EOMI, icteric, OP clear, dry mucous membranes Neck: RIJ line in place, no erythema CV: RRR, nl s1, s2, no m/g/r Lungs: expiratory wheezes throughout Abd: BS+, soft, NT, tympanic, no dullness Ext: warm and well-perfused, no edema Neuro: A&Ox3 CN 2-12 intact, [5-17] UE strength, 3+/5 hip flexors, o/w [5-17] LE strength, reflexes not elicited in biceps, patellar or ankles bilaterally Skin: yellow Pertinent Results: Labs/Studies: ADMISSION LABS: WBC-19.3* RBC-4.43* Hct-42.0 MCV-95 Plt Ct-164 Neuts-88* Bands-7* Lymphs-2* PT-17.8* PTT-60.0* INR(PT)-1.7* Fibrino-656* Glucose-121* UreaN-26* Creat-1.0 Na-131* K-3.3 Cl-96 HCO3-22 AnGap-16 ALT-89* AST-170* LD(LDH)-353* CK(CPK)-1687* AlkPhos-301* Amylase-108* TotBili-14.8* DirBili-13.0* IndBili-1.8 Lipase-263* Albumin-2.4* Calcium-7.2* Phos-2.4* Mg-1.5* [2154-5-13] 12:18AM BLOOD Cortsol-32.7* [2154-5-13] 02:06AM BLOOD Cortsol-45.0* HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE BLOOD HCV Ab-NEGATIVE DISCHARGE LABS: [2154-5-18] 04:45AM BLOOD WBC-11.1* RBC-4.38* Hgb-14.6 Hct-41.7 MCV-95 MCH-33.2* MCHC-34.9 RDW-15.1 Plt Ct-328 [2154-5-18] 04:45AM BLOOD Plt Ct-328 [2154-5-18] 04:45AM BLOOD Glucose-82 UreaN-34* Creat-1.1 Na-132* K-3.3 Cl-96 HCO3-28 AnGap-11 [2154-5-18] 04:45AM BLOOD ALT-63* AST-68* AlkPhos-296* TotBili-3.9* [2154-5-13] 06:00AM BLOOD Lipase-225* [2154-5-18] 04:45AM BLOOD Mg-1.8 EKG at OSH: AF with RVR and new RBBB (by report) . [2154-5-11] head CT - no intracranial hemorrhage, mass effect, shift of normally seen midline structures or hydrocephalus. [Doctor Last Name 352]/white matter differentiation is well maintained. osseous and soft tissue structures are unremarkable. visualized paranasal sinuses and mastoid air cells are clear. . [2154-5-11] Chest CT - There is a large hiatal hernia extending to both hemithoraces with associated adjacent atelectasis. No infiltrate or pleural effusion is seen. The remaining mediastinal structures are unremarkable. The visualized portion of the abdominal organs are unremarkable. . [2154-5-11] Portable Chest - comparison was made to prior study dated [2152-3-28]. There is a large hiatal hernia with associated adjacent atelectasis. No pleural effusion or infiltrate seen. . [2154-5-11] Abdominal ultrasound - Gallbladder is not significantly distended. No significant gallbladder wall thickening. There is intrahepatic and extrahepatic biliary ductal dilatation. The CBD measures 1.0 cm which is abnormally dilated for the patient's age. There is normal appearance of the liver and bilateral kidneys. The right kidney measures 10.9 cm and the L kidney length measures 12.0 cm. The spleen measures 9.9 cm. Limited evaluation of the pancreas, abdominal aorta and IVC. Large amount of biliary sludge is identified within the gallbladder but gallstones are not identified. EKG here: NSR at 92 (seems to be sinus rhythm - p waves seen in V1, but difficult to see elsewhere, regular rate), nl axis, 1st degree AV block, RBBB, TW in III, V1 ERCP: single CBD stone removed with drainage of frank pus. Brief Hospital Course: 77 yo M with ascending cholangitis with hypotension and acute renal failure admitted to the ICU. Hospital course outlined by problem: . # ASCENDING CHOLANGITIS - Due to choledocholithiasis. The pt had an abd US prior to the procedure showing CBD dilation to 1.4cm (OSH 1.0). His initially white counte was elevated with 7% band forms. He was intubated for an emergent ERCP where a common bile duct stone was removed followed by drainage of frank pus. A biliary stent was placed. It was elected to bring him back for a repeat ERCP in one month for stent removal followed by sphincterotomy at that time. He was continued on unasyn. His wbc, fevers, total bilirubin, pancreatic enzymes, and liver enzymes all improved after the stone was removed. He was transitioned to ciprofloxacin for a total of 10 days (total 14 day course of antibiotics ending [2154-5-23]). He was not evaluated by general surgery while here but will see his primary care physician to have an evaluation closer to home. He will need to wait 6 weeks before having this done to limit complications from concurrent pancreatitis (biliary leak, poor anastamosis, etc). Blood cultures remained sterile throughout his stay. . # HYPOTENSION - Thought from his biliary sepsis. WAs continued on pressors but these were weaned quickly with IVF resusciation and treatment of his obstruction. A transthoracic echocardiogram was performed which demonstrated normal LV function (no wall motion abnormalities and an ejection fraction >55%). His e/a ratio was >1 suggesting either pseudonormalization or normal diastolic relaxation. Given that his blood pressure dropped when his ventricular rate rose with atrial fibrillation it is likely that he may have decreased compliance of his LV from longstanding hypertension. He became hypertensive during hospitalization, and was restarted on metoprolol and enalapril, but home HCTZ was held in the post pancreatitis period. . # ATRIAL FIBRILLATION WITH RAPID VENTRICULAR RESPONSE - He continued to have atrial fibrillation throughout his stay here. Prior to transfer he had had a single episode of atrial fib >1 yr ago but this had resolved. Then on presentation to his initial hospital, he was noted to be in atrial fibrillation and would develop a rapid ventricular response associated with drops in his blood pressure. After his hypotension resolved, we increased his lopressor to maintain better rate control. His rate decreased with this as well as with continued treatment of his cholangitis - less catecholamines likely led to less AV nodal conductivity. His CHADS2 score is 2 and so he will benefit from anticoagulation for stroke prevention in the long run. However we elected not to start coumadin prior to discharge given his need to undergo sphincterotomy in 1 month. After this is performed, coumadin may be started by his primary care physician. [Name10 (NameIs) ] was discharged on aspirin and metoprolol. . # RESPIRATORY FAILURE - Intubated for airway protection and general anesthesia for the ERCP then kept intubated until the morning. Extubated on next day without difficulty. AFter extuabation he was noted to have some stridor on physical exam and so was treated with a short course of IV Decadron. This stridor improved and was never associated with an increase in work of breathing. . # RHABDOMYOLOSIS - Likely related to his fall with immobility for 5 hrs as well as his systemic inflammatory response from cholangitis. He did have acute renal failure. He was hydrated aggressively to maintain a urine output >100cc/hr. His creatine and CKs iomproved over the next several days. . # ACUTE RENAL FAILURE - Urine studies suggested a prerenal etiology most likely from his hypotension from sepsis. Rhabdomyolysis may have contributed to some of the renal toxicity as well as his SIRS response to infection. This improved with aggressive hydration and treatment of his infection and he was at baseline at discharge. . # REHAB He was evaluated by physical therapy who noted him to be well below his baseline. He was transferred to a rehab center for further care once his medical issues were resolved. Follow up with the ERCP division was arranged while he was here. He will need to be evaluated by general [Doctor First Name ] for a cholecystectomy in 6 weeks as well as be started on coumadin for his atrial fibrillation. Medications on Admission: prilosec 150 mg vaseretic (enalopril/HCTZ) 10/25 QD allopurinol 300 mg PO QD? Metoprolol (tartrate?) 25 mg QD Ecotrin 325 mg QD . Transfer medications: Neosynephrine drip at 100 mcg/min Diltiazem drip 5 mg/hr Bicarb D5 with 3 Amps 150 cc/hr Heparin drip 1250 U/hr Gentamicin x 1 Unasyn Q6, next dose at 2 AM Levaquin 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 for constipation. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj Injection TID (3 times a day): may discontinue when ambulating adequately. 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours: maximum 2 grams daily. 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 9. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days: last day [2154-5-23]. 11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB/wheeze. 13. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 25759] & Rehab Center - [Location (un) ] Discharge Diagnosis: gallstone pancreatitis ascending cholangitis atrial fibrillation with rapid ventricular response congestive heart failure from arrythmia hypotension respiratory failure with intubation Discharge Condition: stable, feeling well and ready for rehabilitation Discharge Instructions: If you have any abdominal pain, yellowing of the skin, fever, nausea, vomiting, then contact your primary care physician immediately or return to the ED. Followup Instructions: Please get a follow up ERCP as scheduled: Provider: [Name Initial (NameIs) ] SUITE GI ROOMS Date/Time:[2154-6-17] 9:30 Provider: [Last Name (NamePattern4) ]. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Phone:[Telephone/Fax (1) 463] Date/Time:[2154-6-17] 9:30 . GENERAL SURGERY: Ask your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 7962], to have you see a general surgeon to evaluate you for taking out your gallbladder in 6 weeks. . Primary Care follow up: Please schedule a follow up appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 7962] (PCP) within 7 days of leaving the hospital. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1672] MD, [MD Number(3) 1673]	[ "V15.88", "786.1", "577.0", "995.92", "427.31", "576.1", "518.81", "274.9", "038.9", "401.9", "458.8", "574.41", "728.88", "584.9", "428.0", "276.1" ]	icd9cm	[ [ [] ] ]	[ "51.87", "00.17", "38.93" ]	icd9pcs	[ [ [] ] ]	13989, 14075	7855, 12245	338, 344	14303, 14354	5127, 5141	14556, 15095	4528, 4549		12615, 13966		14096, 14282		12271, 12401				14378, 14533					5721, 7832								4564, 5108									15106, 15402																	228, 300						12423, 12592	372, 3996						5157, 5704											4018, 4284	4300, 4512
82,722	138,836	36201	Discharge summary	report	Admission Date: [2161-11-25] Discharge Date: [2161-11-26] Date of Birth: [2081-9-22] Sex: F Service: MEDICINE Allergies: Codeine Attending:[Last Name (NamePattern4) 290] Chief Complaint: upper gi bleed Major Surgical or Invasive Procedure: embolization of History of Present Illness: 80F h/o colon CA s/p colectomy c/b intracutaneous fistula, COPD, [Hospital ] transfer from [Hospital6 33] for IR embolization of bleeding duodenal ulcer. . Admitted to OSH today from rehab after syncopal event described as diphoresis and 'twitching'. Also complained of LUQ abdominal pain. Developed coffee ground emesis and underwent EGD which revealed clot, which was dislodged revealing bleeding duodenal ulcer. The bleeding was unable to be endoscopically managed and surgery was consulted, who refused intervention. Hct decreased from 34 to 25 despite 6 units pRBC. Hypotensive on levophed gtt. Also receiving IV protonix and octreotide gtt. Coags notable for INR 2, receiving FFP en route. IR contact[Name (NI) ] and accepted patient for embolization. Transfer to [Hospital1 18] ICU. Past Medical History: Colon CA s/p colectomy c/b intracutaneous fistula COPD DM Obesity Mild dementia Social History: Current smoker. No EtOH or illicits. Lives currently at rehab. Family History: NC Physical Exam: Physical Examination General Appearance: Overweight / Obese Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic) 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 : ) Abdominal: Soft, Non-tender, Distended Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t) Clubbing Skin: Cool, No(t) Rash: , No(t) Jaundice Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated, Tone: Not assessed Pertinent Results: [2161-11-26] 12:00AM BLOOD WBC-29.4* RBC-3.51* Hgb-10.9* Hct-32.2* MCV-92 MCH-31.1 MCHC-33.9 RDW-14.0 Plt Ct-63* [2161-11-26] 01:28PM BLOOD WBC-17.4* RBC-1.58* Hgb-5.1* Hct-13.7* MCV-87 MCH-32.1* MCHC-37.1* RDW-14.9 Plt Ct-122* [2161-11-26] 12:40AM BLOOD Neuts-78* Bands-4 Lymphs-7* Monos-0 Eos-0 Baso-0 Atyps-3* Metas-4* Myelos-4* [2161-11-26] 12:00AM BLOOD PT-22.1* PTT-150* INR(PT)-2.1* [2161-11-26] 01:28PM BLOOD PT-28.2* PTT-86.3* INR(PT)-2.8* [2161-11-26] 12:00AM BLOOD Fibrino-59* [2161-11-26] 12:40PM BLOOD Fibrino-115* [2161-11-26] 12:00AM BLOOD Glucose-561* UreaN-38* Creat-1.2* Na-144 K-5.6* Cl-113* HCO3-11* AnGap-26* [2161-11-26] 12:40PM BLOOD Glucose-443* UreaN-40* Creat-1.8* Na-144 K-6.0* Cl-105 HCO3-11* AnGap-34* [2161-11-26] 12:00AM BLOOD ALT-46* AST-65* LD(LDH)-393* AlkPhos-39 Amylase-87 TotBili-0.7 [2161-11-26] 12:00AM BLOOD Lipase-83* [2161-11-26] 12:00AM BLOOD Albumin-1.1* Calcium-6.3* Phos-11.6* Mg-1.9 [2161-11-26] 12:40PM BLOOD Calcium-5.8* Phos-10.4# Mg-1.5 [2161-11-26] 12:11AM BLOOD Type-ART Temp-33.6 pO2-131* pCO2-41 pH-7.05* calTCO2-12* Base XS--19 [2161-11-26] 12:52PM BLOOD Type-ART Temp-36.7 Rates-30/0 Tidal V-600 PEEP-5 FiO2-50 pO2-119* pCO2-28* pH-7.24* calTCO2-13* Base XS--13 -ASSIST/CON Intubat-INTUBATED [2161-11-26] 05:59AM BLOOD Lactate-13.1* K-5.6* [2161-11-26] 12:52PM BLOOD Lactate-14.9* K-5.8* [2161-11-26] 08:00AM BLOOD O2 Sat-96 [2161-11-26] 08:00AM BLOOD freeCa-0.79* [2161-11-26] 12:52PM BLOOD freeCa-0.75* Brief Hospital Course: 80F h/o colon CA s/p colectomy c/b enterocutaneous fistulas, COPD with massiv duodenal bleed transferred for embolization. She was hypotensive on arrival and continued to be so until her death. Although she had an embolization of a bleeding vessel by IR on transfer, she continued to bleed via her OGT despite attempts to correct her coagulopathy via FFB, cryoprecipitate and platelets and up to 20 U of PRBC. Her family did not wish for surgical intervention and asked for her to be made comfort measures. She died shortly thereafter. . # UGIB: Duodenal ulcer on EGD. Failed endoscopic control, transferred for IR embolization. Hemodynamically unstable. - IR to evaluate - CVL and PIVs - T&X 9 units - IV protonix and octreotide gtt - q4h hct - continue levophed gtt - stat coags on arrival, FFP for goal INR<1.5 - Consider GI and surgery evaluations Medications on Admission: neurontin 600 [Hospital1 ] lasix 10 daily lisinopril 10 daily cymbalta 30 daily aspirin 81 daily glipizide prednisone protonix advair insulin sc sliding scale . Meds at transfer: Octreotide gtt Protonix gtt Solumedrol IV Zosyn Fentanyl Levophed gtt Vitamin K 10mg Discharge Medications: N/C Discharge Disposition: Expired Discharge Diagnosis: Upper GI bleed Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "V44.3", "569.81", "276.2", "250.00", "275.3", "278.00", "V66.7", "532.00", "288.60", "496", "V10.05", "785.59", "294.8", "286.6", "276.1", "275.41", "584.9", "305.1", "V58.65", "276.7" ]	icd9cm	[ [ [] ] ]	[ "44.44", "88.47", "99.06", "45.13", "96.71", "99.07", "99.04", "38.93" ]	icd9pcs	[ [ [] ] ]	4884, 4893	3673, 4538	292, 309	4951, 4960	2105, 3650	5012, 5154	1345, 1349		4856, 4861		4914, 4930		4564, 4833				4984, 4989													1364, 2086																										238, 254							337, 1145																	1167, 1248	1264, 1329
31,334	156,101	31121	Discharge summary	report	Admission Date: [2193-6-25] Discharge Date: [2193-6-27] Date of Birth: [2119-2-27] Sex: F Service: MEDICINE Allergies: Aspirin / Iodine; Iodine Containing / Fish Product Derivatives / Sulfa (Sulfonamides) / Ibuprofen / Shellfish Attending:[First Name3 (LF) 425] Chief Complaint: Aspirin desensitization prior to elective cardiac catheterization Major Surgical or Invasive Procedure: 1. Aspirin desensitization 2. Cardiac Catheterization with placement of Cypher stent to RCA History of Present Illness: 74 year old woman with pmhx of HTN, PVD, hyperlipidemia, presenting for aspirin densensitization prior to cath. She has had increased SOB for the past few months, including some dyspnea at rest, otherwise no orthopnea, leg swelling, weight gain. She underwent a stress test recently showing possible anteroseptal ischemia. She will undergo diagnostic catheterization after aspirin desensitization. Her history of allergy to aspirin dates back 20+ years. At the time, she used to consume aspirin quite frequently for headaches. However, she noticed at one point that taking aspirin caused numbness and tingling in her mouth/throat. She never had a rash or anaphylaxis. She stopped taking aspirin 20 years ago. Ibuprofen gave her the same symptoms of numbness/tingling as aspirin. On review of symptoms, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. She admits to increasing dyspnea on exertion, sometimes at rest, weight loss of ~10 pounds, unintended, and cough when she lies flat for the past few months. * Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. It is significant for DOE as described above. Past Medical History: PVD HTN - since [06] yrs old Hyperlipidemia CEA [2186] Appendectomy Tonsillectomy GERD Uterine Prolapse Surgery Social History: The patient is a retired nurse. She has five children Family History: Premature CAD Father died 59 with MI and CVA Brother MI at 39, stroke 59 Son with bypass at 52 years of age, 1 with DM Physical Exam: VS: T afebrile, BP 150/58, HR 59, RR 16 , O2 98 % on RA Gen: WDWN middle aged woman in NAD, respiratory or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with no JVD CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. 3/6 systolic murmur at RUSB radiating to carotids. [12-25] diastolic murmur at LUSB. Chest: No chest wall deformities, scoliosis or kyphosis. Respiration was unlabored, no accessory muscle use. Fine crackles at both lung bases, almost to midlung on the R. Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: [2193-6-25*] 06:00PM WBC-5.6 RBC-4.23 HGB-13.1 HCT-35.9 MCV-85 MCH-30.9 MCHC-36.4* RDW-13.9 [2193-6-25] 06:00PM GLUCOSE-100 UREA N-14 CREAT-0.8 SODIUM-142 POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-27 ANION GAP-16 [2193-6-25] 06:00PM CALCIUM-10.1 PHOSPHATE-3.4 MAGNESIUM-2.3 [2193-6-25] 06:00PM PT-12.7 PTT-27.7 INR(PT)-1.1 . . Chol 173, Trig 68, HDL 97, LDL 62 . . EKG demonstrated NSR 52bpm NA, NI, TWI V1. q waves in II, III, AVF old. . Baseline SR small q waves in II, II, AVF, . 2D-ECHOCARDIOGRAM performed on [2193-5-29] demonstrated: Normal LV systolic function and wall motion. Normal RV systolic Function, Minimal aortic stenosis. Trace aortic insufficiency, mild mitral regurgitation and mild tricuspid regurgitation. Trace-to-mild pulmonary insufficiency. Mildly increased pulmonary artery systolic pressures. No pericardial effusion. EF 50%. . ETT performed on [2193-5-29] demonstrated: Treadmill Cardiolite, with SPECT imaging, anteroseptal hypoperfusion. Impression, Normal Wall motion, EF 71%. Suspicious of anteroseptal, ?anteroapical . . [2193-6-26] Cardiac Catheterization - 70% stenosis proximal RCA, LAD with diffucse heavy calcification,30% mid LAD, 50% D1. Cypher stent x1 to proximal RCA LVEF 59% on LV ventriculography COMMENTS: 1. Coronary angiography in this right dominant system demonstrated one vessel disease. The LMCA had no angiographically apparent disease. The LAD had diffuse heavy calcification with a 30% stenosis in the mid section and 50% stenosis of diag 1. The circumflex had no agngiographically apparent disease. The RCA was a large vessel with diffuse heavy calcification and a 70% ostial stenosis. 2. Resting hemodynamics revealed normal left-sided filling pressures with an LVEDP of 15 mmHg. 3. There was no evidence of aortic stenosis. 4. Left Ventriculography revealed no mitral reurgitation. The LVEF was calculated to be 59% with normal wall motion. 5. Cypher stent which was postdilated to 3.5mm. Final angiography revealed 0% residual stenosis, no angiographically apparent dissection and TIMI 3 flow (see PTCA comments). Summary :Successful PTCA and stenting of the RCA. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Normal ventricular function. Brief Hospital Course: 74 W with pmhx of aspirin allergy, and possible anteroseptal ischemia, admitted for elective catheterization after aspirin desensitization. #) Aspirin allergy- Necessary for cardiac cath, patient has not had aspirin in 20 years. The aspirin desensitization protocol was followed, 10 escalating doses of aspirin, 50 mg benadryl 60 min prior to initiation of protocol. She tolerated desensitizatio well without complication. Post cardiac catheterization she did not experience any hives, shortness of breath or any other complications. In addition she tolerated aspirin and plavix following cardiac catheterization without complication. . #) Cardiac Ischemia- antero/septal ischaemia suggested by stress, admitted for elective cardiac catheterization. Cath revealed 70% stenosis of proximal RCA, s/p Cypher stent to RCA. She was premedicated prior to cath with prednisone, benadryl and zantac. Post cath EKG with no significant change compared with prior. No bruit or hematoma of R femoral artery. She did well post cath with no chest pain, shortness of breath or any complications. Discharged on atorvastatin, ASA, Plavix. Follow up arranged with Dr. [Last Name (STitle) 656] her cardiologist. . #) Pump- No signs or symptoms of heart failure, normal ejection fraction of 59% on ventriculography. . #) HTN: restarted on home dose of antihypertensive medications, doxazosin, Cartia XT and HCTZ. . #) GERD: Cont OP Meds . #) leukocytosis - with elevation of WBC to 12.9, most likely [12-21] to cardiac cath and stenting. No symptoms suggestive of infection and she remained afebrile. She will follow up with her PCP if she develops any symptoms concerning for infection. . #) Fen: potassium repleted for . #) Code Status: Full Code Medications on Admission: Cartia XT 300mg Daily HCTZ 25 mg Daily Cardura 2mg qam, 4mg qpm Lipitor 10mg Daily Protonix 20mg Daily Mandelamin 1g [Hospital1 ] for UTI Vit C 1500mg Daily Advair 500/50 mcg [Hospital1 ] . Discharge Medications: 1. Cartia XT 300 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. Capsule, Sust. Release 24 hr(s) 2. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO qAM. Tablet(s) 3. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:3 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 10. Mandelamine 1 g Tablet Sig: One (1) Tablet PO twice a day. Tablet(s) Discharge Disposition: Home Discharge Diagnosis: Primary: 1. CAD - single vessel CAD s/p placement of cypher stent to RCA 2. Aspirin Desensitization . Secondary: PVD HTN Hyperlipidemia GERD s/p CEA [2186] s/p Appendectomy s/p Tonsillectomy s/p Uterine Prolapse Surgery Discharge Condition: Good. Patient is afebrile, hemodynamically stable with normal oxygen saturation on room air Discharge Instructions: You were admitted to the hospital for aspirin desensitization and elective cardiac catheterization. You had a drug-eluting stent placed in your right coronary artery. 1. Please take all medications as prescribed. No changes were made to your home medications. Aspirin and Plavix were added. It is very important that you take plavix every day. If you stop the plavix you could have blockage of the stent in your heart artery which could cause a heart attack. . 2. Please keep all outpatient appointments . 3. Please return to the hospital or contact EMS immediately for any symptoms of shortness of breath, chest pain, nausea/vomiting, fevers/chills or any other concerning symptoms. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 656] on Monday [7-15] at 2:45. They did not have an available appointment on Wed or Friday. Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 6256] Call to schedule appointment	[ "443.9", "272.4", "530.81", "414.01", "401.9" ]	icd9cm	[ [ [] ] ]	[ "88.55", "00.40", "36.07", "99.12", "37.22", "99.20", "88.53", "00.45", "00.66" ]	icd9pcs	[ [ [] ] ]	8578, 8584	5601, 7351	436, 530	8852, 8946	3332, 5488	9683, 9979	2229, 2349		7600, 8555		8605, 8831		7377, 7577		5505, 5578		8970, 9660													2364, 3313																										330, 398							558, 1998																	2020, 2142	2158, 2213
65,705	180,003	35509	Discharge summary	report	Admission Date: [2108-1-24] Discharge Date: [2108-1-31] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 1838] Chief Complaint: Increased confusion Major Surgical or Invasive Procedure: None History of Present Illness: The pt is a [Age over 90 ] year-old right-handed man with a PMH of HTN, HLD, afib off Coumadin and a recent R sided ICH. This history is from his family as well as the transfer records. Mr. [Known lastname ] was admitted to [Hospital1 2025] last week after having a report R thalamic bleed. His Coumadin was stopped and his family believes that they were told that the etiology was from HTN. He was then discharged to a NH where he was found "unresponsive today". His wife witnessed the episode and states that he was "unresponsive" meaning that he would not answer questions and was just counting from 1-100 but missing numbers here and there. He was slightly more dysarthric than his baseline since the stroke but was not more appreciably week on the L side per his family. he was also very sleepy. He was taken to an OSH. . At [Hospital1 ], his BP was 136/72-203/127 and his BS was 116. A CT was obtained which showed a R lateral ventricle acute bleed, measuring 1.2x1.8 cm with mild vasogenic edma. His screening labs showed plts of 288 and INR of 1.28 and a troponin of 0.1. The CK was 70 There were T wave inversions in the precordial leads which are reportedly old and a CXR which showed a L pleural effusion. He was given 2 units of FFP and transferred here for further care as [Hospital1 2025] is on diversion. Past Medical History: - R sided cerebral hemorrhage w/ L sided weakness, dysarthria and dysphagia d/c'd from [Hospital1 2025] on Friday - afib but not on comadin - HTN - mesothelioma - recent PNA and UTI - b12 deficiency - sinus node dysfunction - HLD - prostate ca Social History: -lives at [Location ] -EtOh: denies -tobacco: denies -drugs: denies Family History: NC Physical Exam: Vitals: T: 98.4 P: R: 16 BP: [Telephone/Fax (3) 80873]-81 SaO2: 100% 2L General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. . Neurologic: -Mental Status: very drowsy, arouses to nox stim and localizes with the R arm. Answers no to pain but does not answer other questions consistently and only counts [1-7] skipping numbers intermittently then going to 60-70 etc.. . CN I: not tested II,III: no blink to threat on the L, does not cooperate with VF testing, pupils 2mm->1mm bilaterally, unable to visualize fundi normal III,IV,V: EOMI with head movements. no ptosis. No nystagmus V: + corneals & blink VII: L facial VIII: UA IX,X: + gag [Doctor First Name 81]: UA XII: UA . Motor: decreased tone on the L arm and leg; paratonia ? on the R arm with resting tremor. does not cooperate with formal strenght testing but raises R arm and leg spontenously to nox stim briskly. No movement of L arm to nox stim. Flextion at hip to nox stim on the L leg. . Reflex: No clonus [Hospital1 ] Tri Bra Pat An Plantar C5 C7 C6 L4 S1 CST L 2 2 2 1 0 up R 1 1 1 1 0 Flexor . -Sensory: withdraws to nox stim on the R arm and leg as well as the L leg. . -Coordination: UA . -Gait: UA Pertinent Results: Admission Labs: [2108-1-24] 08:52PM PT-14.7* PTT-26.0 INR(PT)-1.3* [2108-1-24] 08:52PM NEUTS-73.0* LYMPHS-18.6 MONOS-7.6 EOS-0.3 BASOS-0.5 [2108-1-24] 08:52PM WBC-6.6 RBC-3.77* HGB-12.4* HCT-35.8* MCV-95 MCH-32.8* MCHC-34.6 RDW-15.0 PLT COUNT-272 [2108-1-24] 08:52PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2108-1-24] 08:52PM CALCIUM-9.5 PHOSPHATE-3.9 MAGNESIUM-2.4 [2108-1-24] 08:52PM ALT(SGPT)-25 AST(SGOT)-27 CK(CPK)-77 ALK PHOS-60 TOT BILI-1.0 LIPASE-33 [2108-1-24] 08:52PM GLUCOSE-120* UREA N-26* CREAT-0.8 SODIUM-141 POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-28 ANION GAP-14 [2108-1-24] 11:15PM URINE RBC-0-2 WBC-[6-6]* BACTERIA-FEW YEAST-NONE EPI-0-2 [2108-1-24] 11:15PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2108-1-24] 11:15PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.019 [2108-1-24] 11:15PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG . Head CT [1-25]: FINDINGS: A stable hyperattenuating focus with ill-defined borders is again noted centered in the right thalamus. Surrounding hypoattenuation in the right basal ganglia and unaffected thalamus is again seen and consistent with vasogenic edema. Minimal 2 mm leftward shift of normally-midline structures is again noted and stable. No definite intraventricular hemorrhage is identified. . Ill-defined hypoattenuation within the bifrontal subcortical white matter is unchanged and suggests encephalomalacia as sequelae of remote infarction or contusion. . Visualized paranasal sinuses and mastoid air cells appear clear. A small left [Doctor Last Name 13856] bullosa is again noted without significant narrowing of the nasal airway. . IMPRESSION: Stable right thalamic hemorrhage with surrounding edema and 2-mm leftward shift of normally midline structures. No hydrocephalus, herniation or evidence of transependymal dissection of hemorrhage. Brief Hospital Course: The pt is a [Age over 90 ] year-old RH man with multiple medical problems including afib off Coumadin and a recent ICH on the R side (R BG/thalamic hemorrhage) which was treated at [Hospital1 2025]. He was transferred here from an OSH after being lethargic and confused at the NH. At the OSH, he was found to have a R BG bleed with slight edema. This image is not significantly changed from the scan he had here. Initially, scans frmo [Hospital1 2025] were not available for comparison. Clinically he was hypertensive to the 200's and required a labetolol drip to lower his BP. He lethargic but arousable and localizes to pain. He has a L hemiplegia. In regards to his poor mental status, unlikely due to the subacute hemorrhage, hence he has complete infectious work-up including CXR, UA and blood culture. He also had EEG to rule out seizures which may cause confusion but there were no epileptiform activity concerning for seizures. CXR showed improving aeration and UA and blood cutlure were negative. Given that there was no explanation for his increased confusion, MRI was tried to assess for possible frontal lobe infarct but the patient did not tolerate the MRI. He does have stable, old, left frontal infarct. His records from the [Hospital1 2025] were brought in per son, Mr. [First Name8 (NamePattern2) ] [Known lastname ] and it showed that the hemorrhage is indeed shrinking. He had normal CTA at [Hospital1 2025] and normal echocardiogram as well hence further evidence of hemorrhage from uncontrolled hypertension. He was evaluated per physical and occupational therapists during this admission who recommended return to acute rehab for intense, inpatient therapy. Medications on Admission: - Colace 100mg PO BID PRN - senna 2 tabs [Hospital1 ] PRN - fragmin 2500 units SQ Qday - fleets enema prn - milk of mag PRN - fleets enema - tylenol PRN - bisacodyl PRN - prilosec 20mg PO QD - enalapril 20mg PO BID - FE supplements - vit B12 500mcg PO QD - MVI 5mg PO QD - Vicodin PRN - levofloxacin 500mg PO QD x 5 days (unknown start or stop date) - acidophyllus w/ pectin TID x 5 days - metoprolol 25mg PO TID - simvastatin 20mg PO QD Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed: As needed for pain and/or T > 100.4. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO QID (4 times a day). 4. Enalapril Maleate 10 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Heparin SC 5000 U SC TID Discharge Disposition: Extended Care Facility: [Location (un) 14468] Nursing & Rehabilitation Center - [Location (un) 1456] Discharge Diagnosis: Subacute right basal ganglia hemorrhage likely from hypertension Discharge Condition: Stable - Oriented to self only but fluent speech - voluntarily moves right arm and leg with good resistance but left side with little spontaneous movement and not able to hold antigravity but leg stronger than arm. Discharge Instructions: You were admitted after being found to have increased confusion and lethargy at the nursing home where you have been since discharge from [Hospital ] [Hospital 80874] Hospital where you were admitted for right basal ganglia hemorrhage. Initially, your records were not available to assess whether the hemorrhage has changed but the evaluation including CT scans here showed that the hemorrhage was not acute. During this admission, your records including the discharge summary and the films from [Hospital1 2025] were brought in by your family and the review of the records show that your hemorrhage had definitely decreased in size. Given your confusion, you were worked for possible infectious/metabolic etiology but everything was negative and you also had an EEG to rule out seizure activity. MRI was tried to assess for possible new, frontal lobe stroke/ischemia but you did not tolerate the MRI study. CT of head was repeated again to see if there are signs of acute/subacute stroke but only an old left frontal lobe stroke was noticed in addition to the decreasing right basal ganglia hemorrhage. Please continue to take meds as prescribed. Given the hemorrhage, continue to avoid antiplatelet agents such as aspirin or ibuprofens. Please do not restart Coumadin. You will be following up with Dr. [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] (neurology) as outpatient - you will be given further instructions about medications at that time. Please call your doctor if you have new weakness, speech problems including slurring, unabating headache and/or concerns. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 640] [Last Name (NamePattern4) 3445], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2108-3-2] 2:00 - [Hospital Ward Name 23] Clinical Center [Location (un) 858] (Please have family member call [Telephone/Fax (1) 2574] prior to the appointment to update demographic/insurance information). Completed by:[2108-1-31]	[ "427.31", "293.0", "266.2", "401.9", "431", "V10.46" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	8475, 8586	5742, 7460	291, 298	8694, 8910	3683, 3683	10606, 11021	2046, 2050		7953, 8452		8607, 8673		7486, 7930				8934, 10583													2065, 2601																										232, 253							326, 1667						3700, 5719					2616, 3664						1689, 1938	1954, 2030
58,991	132,518	42408	Discharge summary	report	Admission Date: [2101-10-4] Discharge Date: [2101-10-12] Date of Birth: [2049-10-8] Sex: F Service: SURGERY Allergies: Motrin / Erythromycin Base Attending:[First Name3 (LF) 3200] Chief Complaint: Morbid obesity Major Surgical or Invasive Procedure: [2101-10-4]: 1. laparoscopic sleeve gastrectomy and concomitant laparoscopic cholecystectomy. [2101-10-7]: 1. Exploratory laparoscopy converted to laparotomy. 2. Abdominal washout. 3. Oversewing of the gastric sleeve staple line. 4. Evacuation of clot. 5. Liver biopsy. History of Present Illness: [Known firstname ] has class III morbid obesity with a weight of 344 pounds as of [2101-6-27] with her initial screen weight 340 pounds on [2101-5-31], height 66 inches and BMI of 55.5. Her previous weight loss efforts have included Weight Watchers x 36 months [2098]-present losing 50 pounds, the [Doctor Last Name 1729] diet in [2096] for 6 months losing 24 pounds, Slim-Fast x 12 months and [2094] losing [Street Address(1) 91840] visits x 4 as well as PCP counseling since [2084]. She is also undergoing behavioral therapy for past 36 months. She has not taken prescription weight loss medications or used over-the-counter ephedra-containing appetite suppressants/herbal supplements. She stated that her weight at age 21 was 250 pounds her lowest adult weight and her highest weight was 384 pounds in [2097-6-23]. She has had weight issues since age 14 shortly before she was diagnosed with polycystic ovary syndrome and when she graduated from high school she weighed 350 pounds. She subsequently lost 100 pounds and had maintained the loss for the following 15 years. In [2091] she was diagnosed with lupus and was placed on high doses of prednisone and gained 180 pounds over the course of 5 years. Factors contributing to her excess weight include grazing a large portions, some refined carbohydrates and saturated fats as well as stressful and emotional eating. Her current exercise routine is one hour twice per week of aqua-aerobics, one hour of personal training in a pool and one hour of personal training in the gym with resistance training and weights. She attributes difficulty with exercise because of her large pannus and impedance of her mobility. She denied history of eating disorders and does have depression/anxiety, is followed by a therapist working on weight issues, has not been hospitalized for mental health issues and she is on psychotropic medication that she does find useful (Zoloft). Past Medical History: Past Medical History: Her medical history is significant for, 1. Polycystic ovarian syndrome. 2. Rheumatoid arthritis. 3. Discoid lupus. 4. Diabetes mellitus. 5. Depression. 6. Obstructive sleep apnea. 7. CPAP. Past Surgical History: The patient denies any significant surgical history. Social History: She used to smoke two packs of cigarettes daily for 20 years but quit in [2084], denies recreational drug usage, no alcohol and does consume caffeinated beverages. She works as an underwriter and is married living with her husband age 65 retired and her stepson aged 24. Family History: Her family history is noted for mother living at age 70 with diabetes and obesity; paternal grandmother deceased age 78 with heart disease, hyperlipidemia, stroke and arthritis; maternal grandmother deceased age 62 of cancer. Physical Exam: VS: Constitutional: NAD Neuro: Alert and oriented x 3 Cardiac: RRR, NL S1,S2 Lungs: CTA B Abd: Wounds: Ext: Pertinent Results: [2101-10-10] 04:57AM BLOOD WBC-9.5 RBC-3.21* Hgb-9.7* Hct-30.0* MCV-93 MCH-30.3 MCHC-32.5 RDW-14.0 Plt Ct-294 [2101-10-9] 03:35PM BLOOD WBC-8.9 RBC-3.22* Hgb-9.7* Hct-30.6* MCV-95 MCH-30.1 MCHC-31.8 RDW-14.0 Plt Ct-292 [2101-10-9] 02:37AM BLOOD WBC-8.7 RBC-2.99* Hgb-8.9* Hct-28.0* MCV-94 MCH-29.7 MCHC-31.7 RDW-14.2 Plt Ct-281 [2101-10-8] 02:58PM BLOOD Hct-28.8* [2101-10-8] 09:27AM BLOOD Hct-29.4* [2101-10-8] 01:19AM BLOOD WBC-8.2 RBC-3.10* Hgb-9.3* Hct-28.7* MCV-92 MCH-30.1 MCHC-32.5 RDW-14.3 Plt Ct-267 [2101-10-7] 03:30PM BLOOD WBC-12.0* RBC-3.33* Hgb-10.2* Hct-30.5* MCV-92 MCH-30.7 MCHC-33.5 RDW-14.5 Plt Ct-264 [2101-10-7] 12:15PM BLOOD WBC-10.4 RBC-3.27* Hgb-10.0* Hct-30.4* MCV-93 MCH-30.5 MCHC-32.8 RDW-14.3 Plt Ct-280 [2101-10-7] 06:40AM BLOOD Hct-25.1* [2101-10-6] 11:16PM BLOOD Hct-28.3* [2101-10-6] 04:00PM BLOOD WBC-9.8# RBC-3.02# Hgb-9.0# Hct-27.5* MCV-91 MCH-29.9 MCHC-32.9 RDW-14.6 Plt Ct-249 [2101-10-6] 10:35AM BLOOD Hct-28.3* [2101-10-5] 05:27PM BLOOD Hct-29.7* [2101-10-4] 10:10PM BLOOD Hct-30.5* [2101-10-4] 05:58PM BLOOD Hct-31.1* [2101-10-4] 02:44PM BLOOD Hct-34.9* [2101-10-7] 12:15PM BLOOD Fibrino-657* [2101-10-9] 02:37AM BLOOD Glucose-132* UreaN-4* Creat-0.5 Na-143 K-3.5 Cl-108 HCO3-29 AnGap-10 [2101-10-8] 01:19AM BLOOD Glucose-153* UreaN-6 Creat-0.5 Na-145 K-3.7 Cl-110* HCO3-31 AnGap-8 [2101-10-7] 03:30PM BLOOD Glucose-174* UreaN-8 Creat-0.6 Na-142 K-3.7 Cl-107 HCO3-26 AnGap-13 [2101-10-5] 05:27PM BLOOD Glucose-136* UreaN-8 Creat-0.8 Na-145 K-4.2 Cl-107 HCO3-28 AnGap-14 [2101-10-9] 02:37AM BLOOD Calcium-7.8* Phos-3.2 Mg-1.7 [2101-10-8] 01:19AM BLOOD Calcium-7.7* Phos-2.6* Mg-2.0 [2101-10-7] 03:30PM BLOOD Calcium-7.9* Phos-2.6* Mg-1.8 [2101-10-5] 05:27PM BLOOD Calcium-8.3* Phos-2.9 Mg-1.7 [2101-10-7] 12:27PM BLOOD Type-ART pO2-145* pCO2-41 pH-7.40 calTCO2-26 Base XS-0 [2101-10-7] 10:35AM BLOOD Type-ART pO2-199* pCO2-42 pH-7.41 calTCO2-28 Base XS-2 [2101-10-7] 12:27PM BLOOD Glucose-146* Lactate-1.2 Na-140 K-3.6 Cl-110* [2101-10-7] 10:35AM BLOOD Glucose-115* Lactate-0.8 Na-141 K-3.2* Cl-111* [2101-10-7] 12:27PM BLOOD Hgb-11.2* calcHCT-34 [2101-10-7] 12:27PM BLOOD freeCa-0.99* [2101-10-7] 10:35AM BLOOD freeCa-0.97* IMAGING: [2101-10-5] UGI SGL CONTRAST W/ KUB: IMPRESSION: Expected post-operative appearance of sleeve gastrectomy without obstruction or leak [2101-10-5] ECG: Sinus tachycardia. Delayed R wave transition. Left ventricular hypertrophy. Possible prior inferior myocardial infarction. Compared to the previous tracing of [2101-5-31] the ventricular rate is faster and the suggestion of a possible prior inferior myocardial infarction is new. Delayed R wave progression was not previously seen. Brief Hospital Course: The patient presented to pre-op on [2101-10-4]. Pt was evaluated by anaesthesia and taken to the operating room for laparoscopic sleeve gastrectomy and laparascopic cholecystectomy. There were no adverse events in the operating room; please see the operative note for details. Pt was extubated, taken to the PACU until stable, then transferred to the [Hospital1 ] for observation. On POD1, the patient's hematocrit trended downward to 28 (from 41.1 pre-op) with concomittant tachycardia to 110s and sanguinous JP drainage, therefore, she was transfused a total of 2 units of PRBCs; heparin was discontinued. Of note, on POD1, the patient complained of epigastric pain radiating to her left arm; an EKG was reassuring and troponin was within normal limits. An UGI series, also performed on POD1, was negative for a leak, therefore, her diet was advanced to stage 1, which was well tolerated. Urine output remained adequate and the patient was ambulating with assistance. On POD3, due to persistent mild tachycardia, sanguinous JP output and decreasing hematocrit levels to 25 requiring an additional 2 units of PRBCs, the patient returned to the operating room where she underwent an exploratory laparoscopy converted to laparotomy, abdominal washout, oversewing of the gastric sleeve staple line, evacuation of clot and liver biopsy; see operative note for details. Post-procedure the patient was transferred to the surgical intensive care unit for close observation. The patient remained stable in the ICU with resolution of tachycardia and stable hematocrit levels. Pain was well controlled with a dilaudid PCA. An NGT, placed intra-operatively was discontinued and methylene blue dye was administered orally without subsequent change in character of JP drain output, therefore, her diet was advanced to stage 1 and well tolerated. Also, given concern for local tissue ischemia of small portion of patient's wound, a few staples were removed and a dry dressing was applied and changed twice daily. On POD [5-25], the patient was transferred to the general surgical [Hospital1 ]. While on the floor, she continued to have stable vital signs and hematocrit levels; subcutaneous heparin was resumed on [10-8]. Her diet was advanced to Stage 3, which was well tolerated; FSBG was monitored and metformin was resumed at half dose upon discharge. The dilaudid PCA, IVF and foley were discontinued; po meds were initiated. PT evaluated the patient and provided acute treatment with recommendations for continued home PT upon discharge. OT was also consulted but did not identify any acute OT needs. On POD [8-28], the patient was discharged to home with visiting nursing services and home physical therapy. She continued to do well, was afebrile with stable vital signs. The patient was tolerating a stage 3 diet, ambulating, voiding without assistance, and pain was well controlled. Both JP drains were removed prior to discharge. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. She will follow-up with Dr. [Last Name (STitle) ] in clinic in 1 week. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Hydroxychloroquine Sulfate 200 mg PO BID 2. MetFORMIN (Glucophage) 1000 mg PO BID 3. Sertraline 50 mg PO DAILY 4. Vitamin E 1000 UNIT PO DAILY 5. Vitamin D 5000 UNIT PO DAILY 6. Multivitamins W/minerals 1 TAB PO DAILY 7. cinnamon bark NF dosage uncertain tablets Oral daily 8. Calcet Creamy Bites NF (calcium citrate-vitamin D3) 500 mg calcium -400 unit Oral [Hospital1 ] 9. Fish Oil (Omega 3) 1000 mg PO Frequency is Unknown Discharge Medications: 1. OxycoDONE Liquid 5-10 mg PO Q4H:PRN Pain RX oxycodone 5 mg/5 mL [6-2] ML by mouth every four (4) hours Disp #150 Milliliter Refills:0 2. Ranitidine (Liquid) 150 mg PO BID RX ranitidine HCl 15 mg/mL 10 mL by mouth twice a day Disp #600 Milliliter Refills:0 3. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain RX acetaminophen 325 mg/10.15 mL 20 ml by mouth every six (6) hours Disp #300 Milliliter Refills:0 4. Calcet Creamy Bites NF* (calcium citrate-vitamin D3) 500 mg calcium -400 unit Oral [Hospital1 ] 5. Fish Oil (Omega 3) 1000 mg PO DAILY 6. Multivitamins W/minerals 1 TAB PO DAILY 7. Vitamin D 5000 UNIT PO DAILY 8. Miconazole Powder 2% 1 Appl TP TID RX miconazole nitrate [Anti-Fungal] 2 % 1 application twice a day Disp #90 Gram Refills:0 9. Nystatin Oral Suspension 5 mL PO QID:PRN Thrush Duration: 7 Doses Swish and spit RX nystatin 100,000 unit/mL 5 ML by mouth four times a day Disp #140 Milliliter Refills:0 10. Docusate Sodium (Liquid) 100 mg PO BID:PRN Constipation RX docusate sodium 50 mg/5 mL 10 ml by mouth twice a day Disp #150 Milliliter Refills:0 11. MetFORMIN (Glucophage) 500 mg PO BID RX metformin [RIOMET] 500 mg/5 mL 500 mg by mouth twice a day Disp #300 Milliliter Refills:1 12. Sertraline 50 mg PO DAILY RX sertraline 20 mg/mL 50 mg by mouth Daily Disp #75 Milliliter Refills:1 Discharge Disposition: Home With Service Facility: [Hospital1 ] VNA, [Hospital1 1559] Discharge Diagnosis: Morbid obesity Diabetes mellitus. Cholelithiasis. Chronic cholecystitis. Sleep apnea. Intraabdominal bleeding after laparoscopic gastric sleeve and cholecystectomy. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions: Please call your surgeon or return to the emergency department if you develop a fever greater than 101.5, chest pain, shortness of breath, severe abdominal pain, pain unrelieved by your pain medication, severe nausea or vomiting, severe abdominal bloating, inability to eat or drink, foul smelling or colorful drainage from your incisions, redness or swelling around your incisions, or any other symptoms which are concerning to you. Diet: Stay on Stage III diet until your follow up appointment. Do not self advance diet, do not drink out of a straw or chew gum. Medication Instructions: Resume your home medications except for the following changes. 1. Please reduce your metformin to 500 mg, twice daily. Please check your blood sugars twice daily and report elevated or low readings to your prescribing [Provider Number 34259]. Please hold hydroxychloroquine (Plaquenil). Discuss your ability to resume this medication with Dr. [Last Name (STitle) ] at your follow-up visit. CRUSH ALL PILLS* You will be starting some new medications: 1. You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. 2. You should begin taking a chewable complete multivitamin with minerals. No gummy vitamins. 3. You will be taking Zantac liquid 150 mg twice daily for one month. This medicine prevents gastric reflux. 4. You should take a stool softener, Colace, twice daily for constipation as needed, or until you resume a normal bowel pattern. 5. Nystatin oral swish four times per day as needed to treat oral thrush. 6. Miconazole powder applied twice daily to affected area. 5. You must not use NSAIDS (non-steroidal anti-inflammatory drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and Naproxen. These agents will cause bleeding and ulcers in your digestive system. Activity: No heavy lifting of items [11-7] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Department: BARIATRIC SURGERY When: TUESDAY [2101-10-18] at 1 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], RD [Telephone/Fax (1) 305] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: BARIATRIC SURGERY When: TUESDAY [2101-10-18] at 1:30 PM With: [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 13365], MD [Telephone/Fax (1) 3201] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2101-10-13]	[ "250.00", "V15.82", "278.01", "785.0", "998.11", "E878.8", "695.4", "574.10", "998.12", "V85.43", "V64.41", "V13.01", "327.23" ]	icd9cm	[ [ [] ] ]	[ "43.82", "54.12", "51.23", "50.11" ]	icd9pcs	[ [ [] ] ]	11550, 11623	6413, 9593	302, 583	11832, 11832	3587, 6390	14506, 15181	3216, 3443		10184, 11527		11644, 11811		9619, 10161				12007, 12573											2851, 2906		3458, 3568																										248, 264				14149, 14483			611, 2585								12598, 14137			11847, 11959						2630, 2827	2922, 3200
17,857	177,877	10275	Discharge summary	report	Admission Date: [2131-3-16] Discharge Date: [2131-3-26] Date of Birth: [2065-6-28] Sex: M Service: MEDICINE Allergies: Oxycontin Attending:[First Name3 (LF) 6021] Chief Complaint: hematuria, abd pain Major Surgical or Invasive Procedure: Cystoscopy History of Present Illness: 65 Russian-only speaking M with metastatic colon ca on Cycle 1, Day 6 experimental drug (unknown action) of Reata clinical trial, history of extensive PE, presents with SOB and hypoxemia. He was vomiting tonight and desatted to 80% RA and 94% FM on two episodes that followed each other within minutes. ABG on FM: 7.41 / 47 / 315. CXR shows diffuse fluffy infiltrates indicative of pneumonitis but no indication for hypoxemia. He was given lasix with unknown UO (nurses did not monitor), levo/flagyl x 1, and he stabilized to 100% NRB without improvement. CK 69, MB 3, Trop 0.02. During these episodes, patient had sinus tach to 120s, which was not treated. He has a history of extensive PEs but has been compliant with lovenox 100 per day. Over the last day, his WBC increased from 9.9 to 14.8, Hct decreased from 33 to 25.1, Cr increased from 1.2 to 2.0. . He was admitted today with hematuria, abdominal pain, repeated vomiting. Patient has a history of hematuria and has ureteral invasion of his tumor on prior imaging. He was seen in epi clinic on [3-5] for gross hematuria in which his lovenox was decreased from 120 to 100 mg qd and he was given levaquin for treatment of a UTI based off of a positive UA. The pt noticed a slight decrease in his hematuria and was feeling relatively well when he began to have repeat gross hematuria with clots beginning last pm at 8:30. This was associated with a dull, achy pain in the suprapubic area. He initially refused to go to the ED for evaluation; however he was up all night with urinary urge and gross hematuria that he presented for evalution early this am. He denies associated dysuria, flank pain, back pain, fevers, chills, night sweats, n/v/d. The pt reports his last BM was 7 days ago. . In the ED, the pt was seen by urology to placed a 3-way catheter for CBI. He was given mag citrate and fleets enema for large amt of stool seen on KUB and had one small BM. UA was positive with glucose > 1000, ketones positive. . He has been on an experimental drug made by Reata pharmaceuticals called RTA-402, which is an inhibitor of IKK. The drug would thus inhibit NFkB. On the Reata site, states no overt side effects to the drug in administration for 28 days to baboons, but no side effects noted in humans. Past Medical History: PAST ONC HISTORY: The patient initially presented in [2125] for evaluation of mild hematuria when a CT abd showed thickening of the sigmoid colon. A sigmoidoscopy showed a large non-bleeding mass and he underwent sigmoid colectomy which showed moderately differentiated ulcerated adenocarcinoma reaching the serosa with [5-18] lymph nodes were positive for metastasis. Since his initial presentation of stage III colon CA, he has progressed to metastatic disease to the lung, liver, abd wall, ureter. 1. He is status post 5-FU, leucovorin as adjuvant therapy. 2. He is status post 5-FU, irinotecan, and Avastin with disease progression. 3. Status post oxaliplatin and Xeloda. 4. He is status post Erbitux and irinotecan. 5. He is status post Avastin, 5-FU, and mitomycin. He has not received therapy in several months. He has progressed on all these therapies. 6. He developed a PE in [9-17] and is being anticoagulated with Lovenox daily. 7. He was recently placed on a phase 1 Reata clinical trial, which has since been held due to progression of disease. . PMH: 1) Metastatic colon cancer as above 2) HTN 3) Hypercholesterolemia 4) Depression 5) CRI 6) GERD Social History: Lives with wife in [Location (un) ] apt with elevator. Has a home aide. Smokes [5-17] cig/day for the past 50 yrs. Previously was a heavier smoker, up to 1 PPD. Denies EtOH, illicits, IVDA. Family History: No family h/o colon CA. Aunt with rectal CA at the age of 85. Physical Exam: VS: 96.8 / 92 / 113/93 / 24 / 92% NRB General: Responds in broken English, NAD, pleasant male, thin HEENT: No JVD, no LAD, sclerae anicteric, MMM, OP clear LUNGS: CTA b/l HEART: RRR, +s1/s2, no m/r/g ABD: Firm to palpation over epigastric and suprapubic areas (per onc fellow note, this is not new), normoactive BS in all 4 quadrants, distended, no hsm EXTR: No LE edema, +2 DP pulses b/l Pertinent Results: LABS ON ADMISSION: [2131-3-15] 09:55AM WBC-9.6 RBC-3.95* HGB-12.0* HCT-34.5* MCV-87 MCH-30.4 MCHC-34.8 RDW-16.0* [2131-3-15] 09:55AM NEUTS-78.0* LYMPHS-16.3* MONOS-4.5 EOS-1.0 BASOS-0.3 [2131-3-15] 09:55AM PLT COUNT-488# [2131-3-15] 09:55AM PT-13.0 PTT-29.5 INR(PT)-1.1 [2131-3-15] 09:55AM FIBRINOGE-423 [2131-3-15] 09:55AM RET AUT-2.4 [2131-3-15] 09:55AM TOT PROT-6.8 ALBUMIN-3.9 GLOBULIN-2.9 CALCIUM-9.7 PHOSPHATE-2.4* MAGNESIUM-2.0 URIC ACID-5.5 [2131-3-15] 09:55AM ALT(SGPT)-19 AST(SGOT)-16 LD(LDH)-152 ALK PHOS-123* TOT BILI-0.3 [2131-3-15] 09:55AM GLUCOSE-130* UREA N-18 CREAT-1.0 SODIUM-136 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-21* ANION GAP-16 [2131-3-15] 11:00AM URINE COLOR-Red APPEAR-Cloudy SP [Last Name (un) 155]-1.015 [2131-3-15] 11:00AM URINE BLOOD-LGE NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.5 LEUK-TR [2131-3-15] 11:00AM URINE RBC->50 WBC-[1-1]* BACTERIA-RARE YEAST-NONE EPI-[4-16] . KUB [3-16]: Large amount of stool within the large bowel with no evidence of obstruction. . CXR [3-16]: No free air is seen under the diaphragms. In comparison with [2131-1-12], the cardiomediastinal silhouette appears stable. Again noted are innumerable bilateral pulmonary nodules consistent with the patient's history of metastatic colon cancer. No additional focal consolidations or effusions are seen. There is no pneumothorax. . Renal US [3-17]: 1. Moderate-to-severe hydronephrosis in the right kidney with associated parenchymal thinning, not significantly changed from previous CT dated [2131-1-26]. 2. Small amount of echogenic material within the bladder which is consistent with patient's history of intraluminal bladder hematoma. 3. Large mass identified within the region of the bladder likely corresponding to patient's known anterior abdominal wall metastatic disease. . Ureteral mass [3-19]: path pending . Cystoscopy [3-19]: There were noted clots within the proximal urethra and a notably high bladder neck that was also hypervascular. Once in the bladder we were immediately confronted by a large space occupying bladder clot occupying likely [4-15] of the bladder, which was evacuated. A large papillary frondular mass emanating from the right ureteral orifice of approximately 3 x 2 cm, high grade appearing, was resected and sent for pathology. . CT abd/pelvis without contrast [3-20]: 1. No evidence of bowel obstruction. 2. Extensive metastatic disease including innumerable pulmonary nodules, pleural mass, hepatic lesions, omental and abdominal wall disease. The pleural disease and hepatic metastasis appears increased from prior examination. 3. Tiny non-obstructing stone in the left proximal ureter. Otherwise, stable appearance of the kidneys. Irregularity of the bladder is likely related to the prior day's cystoscopy. . CXR [3-22]: 1. Right-sided PICC catheter with tip likely within superior right atrium. Recommend repositioning. 2. Patchy basilar opacities, best appreciated within the right lower lobe are suspicious for areas of aspiration pneumonia or pneumonitis given clinical history. Metastatic burden appears stable/ 3. Probable small bilateral pleural effusions. Brief Hospital Course: 65 yo M with metastatic colon CA and h/o PE presents who presented with hematuria and abdominal pain. The pt was evaluated by urology in the ED who placed a 3 way Foley and a CBI was begun with return of dark, and then bright red urine. He was also given magnesium oxide and lactulose in the ED with 1 small BM. The CBI and a more aggressive bowel regimen were continued on the night of admission when the pt developed emesis and subsequently desated down to the upper 70s on RA. He was placed on a NRB with improvement in sats to the low to mid 90s. An EKG was performed without any ischemic changes. He was transferred to the MICU and started on vancomycin and cefepime for aspiration PNA. There was also a question of whether or not capillary leak could be a side effect from the pt's clinical trial drug, Reata; however, no literature suggesting this was found. Based off of CXR, it was most likely that the pt's hypoxia was secondary to aspiration PNA vs. an aspiration pneumonitis. As the CXR was also significant for vascular congestion, his IVFs were limited and he was diuresed with IV lasix. . While in the MICU, it was noted that the pt continued to have gross hematuria and large blood clots in spite of continuous bladder irrigation. His Hct also fell from 34.5 to 22.3 and his Cr climbed from 1.4 to 3.6. Renal was consulted who felt that the cause of his ARF was most likely post-renal in nature given his known h/o a R ureteral mass and ongoing hematuria. Urology took the pt for cystoscopy in which a large blood clot occupying [4-15] of the bladder was evacuated and a large, high grade appearing R ureteral mass was biopsied and resected. He was transfused a total of 8 U pRBC in the MICU for decreasing Hct, which eventually stabilized out to the upper 20s, low 30s on the floor. . The pt's oxygen requirement was weaned down to 4L NC and he was called out to the floor. As his urine had cleared s/p cystscopy, his CBI was d/c'd and a Foley was placed. Lovenox was titrated up from 40 to a treatment dose of 80 mg SQ qdaily without any increase in hematruia or Hct drop. The pt was also further diuresed and was switched to po levaquin for treatment of PNA. His oxygen requirement was weaned off and he was sating in the mid 90s on RA by time of discharge. Of note, the pt had two seperate urinary void trials without success prior to d/c (bladder scan with 450 cc, 400 cc respectively). He was discharged to rehab with a Foley in place and will f/u with urology in 2 wks time to have the foley removed. He will follow-up with Dr. [Name (STitle) ] for further oncologic care. During the hospital course, Reata was d/c'd given demonstrated progession of disease . Code status: Full Medications on Admission: Ambien 5 mg qhs prn LAC-HYDRIN 12 %--Apply to heels at bedtime Lisinopril 40 mg qd Ativan 0.5 mg [2-13] pills qhs Lovenox 100 mg SQ qd Miralax qd MS Contin 100 mg [Hospital1 ] Oxycodone 5 mg po q4h prn Protonix 20 mg qd Lactulose prn Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:15 Tablet(s) Refills:0 4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. Disp:1 Tablet(s) Refills:0 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. Disp:400 ML(s) Refills:0 8. Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) units Subcutaneous QDAILY (). Disp:1 month supply Refills:2 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 11. Morphine 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:60 Tablet Sustained Release(s) Refills:2 12. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. Disp:60 Tablet, Chewable(s) Refills:0 13. Chlorpromazine 25 mg Tablet Sig: One (1) Tablet PO Q8H PRN () as needed for hiccups. Disp:30 Tablet(s) Refills:0 14. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Primary Diagnosis: Hematuria s/p removal of R ureteral orifice Aspiration PNA Secondary Diagnosis: Metastatic Colon CA HTN Hypercholesterolemia Depression CRI GERD Discharge Condition: Good, ambulating, breathing well on room air, eating regular diet. Discharge Instructions: You were admitted for hematuria, or blood in your urine. A cytoscopy was performed in which a large blood clot was evacuated from the bladder and a mass was removed and biopsied from the R ureteral orifice. You will need to complete a 7 day course of levaquin as an outpatient for treatment of pneumonia. Please take all of your other medications as prescribed. You are being discharged with a Foley catheter in place. You will need to follow-up with urology in 2 weeks to remove the Foley. The phone number for the urology clinic is ([Telephone/Fax (1) 18591]. Please call your physician or return to the emergency room if you experience any of the following: increasing hematuria, abdominal pain, diarrhea, cough, shortness of breath. Followup Instructions: You have the following appointments: Provider [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1879], M.D. Date/Time:[2131-3-28] 10:20 Provider [First Name11 (Name Pattern1) 5445] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5446], DPM Phone:[Telephone/Fax (1) 543] Date/Time:[2131-4-11] 10:20 Provider [First Name8 (NamePattern2) 161] [Name9 (PRE) 162] [Name8 (MD) 163], MD Phone:[Telephone/Fax (1) 921] Date/Time:[2131-4-23] 10:30 Completed by:[2131-3-26]	[ "285.1", "V10.05", "403.90", "599.7", "198.1", "585.9", "272.0", "198.89", "197.0", "591", "799.02", "530.81", "584.9", "507.0", "197.7" ]	icd9cm	[ [ [] ] ]	[ "99.04", "57.49", "38.93" ]	icd9pcs	[ [ [] ] ]	12607, 12677	7839, 10549	290, 303	12886, 12955	4524, 4529	13748, 14283	4036, 4099		10841, 12584		12698, 12698		10575, 10818				12979, 13725													4114, 4505																										231, 252							331, 2598				12798, 12865			12717, 12777		4544, 7816								2620, 3804	3821, 4020
76,001	150,334	41420	Discharge summary	report	Admission Date: [2138-8-22] Discharge Date: [2138-8-29] Date of Birth: [2069-4-18] Sex: M Service: CARDIOTHORACIC Allergies: Dilaudid Attending:[First Name3 (LF) 165] Chief Complaint: Increasing fatigue and SOB Major Surgical or Invasive Procedure: Left thoracentesis drained ~2L History of Present Illness: This is a 69yo male who was seen recently in our office for surgical evaluation for AVR, now transferred from [Hospital6 33] with congestive heart failure after his second admission in recent weeks. He was recently discharged from [Hospital1 18] [2138-8-15] after presenting from rehab with vomiting and abdominal pain x2 days - likely cause determined to be severe constipation, which pt has a history of in the past. He also had a recent PNA. He has known AS and multiple co-morbidities including COPD, diabetes mellitus and chronic renal insufficiency. Given history of AV node dysfunction, he underwent placement of permanent pacemaker in [2138-2-8]. Echo showed severe aortic stenosis and cath revealed two vessel CAD - systolic and diastolic heart failure (EF 40-45%), severe aortic stenosis ([Location (un) 109] 0.8cm2, peak gradient 66mmHg). He is being transferred today to [Hospital1 18] for evaulation for CABG/AVR. Past Medical History: CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension CARDIAC HISTORY:[3-/2138] cath 30% prox LAD. 100% first diagonal, 50% mid LCx, 40% OM1, 100% ostial RCA OTHER PAST MEDICAL HISTORY: - Chronic Diastolic and Systolic Congestive Heart Failure - Aortic Stenosis - Coronary Artery Disease - Chronic Renal Insufficiency (baseline Cr 2.5) - Chronic Obstructive Pulmonary Disease - Cerebrovascular event ([2097], per pt no residual deficits) - Type II Diabetes Mellitus (IDDM) - Post-traumatic stress disorder - Chronic Pain ( fractured lumbar vertebra) - Osteoarthritis left shoulder and leg - Benign prostatic hypertrophy - Left hand neuropathy - Glaucoma in left eye - Colon polyps - Recurrent left pleural effusion 4. PAST SURGICAL HISTORY - Permanent Pacemaker [2138-3-10] - C4-C7 spinal surgery - Right lower extremity vein stripping - Nasal surgery Social History: Tobacco: 1.5 ppd ( 75 PYHx); trying to quit ETOH: 2 per month Lives: Alone, has daughter who spends a lot of time hopitalized for psychiatric reasons Occupation: retired engineer Last Dental Exam: has 6 remaining teeth, uses partials Family History: Brother died of MI at 69. Physical Exam: Admission PE: Pulse: 79 O2 sat: 97% B/P (L)130/78 (R)139/83 Height: 67 inches Weight: 190 lbs General:A&Ox3 Skin: Dry [x] intact [x] loss of skin coloration BUE HEENT: PERRLA [x] EOMI [x]; faint ptosis R eyelid; anicteric sclera Neck: Supple [x] Full ROM [] no JVD Chest: (R)crackles Heart: RRR [x] Irregular [] Murmur 3/6 SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + hypoactive; no HSM/CVA tenderness; obese Extremities: Warm [x], well-perfused [x] Edema: [2-9] BLE (R)LE vein stripping Neuro: Grossly intact Pulses: Femoral Right: 1+ Left : 1+ DP Right: NP left NP PT [Name (NI) 167]: NP Left:NP Radial Right: trace right: trace Carotid Bruit: murmur radiates to B carotids Pertinent Results: [2138-8-29] 06:15AM BLOOD WBC-6.1 RBC-3.34* Hgb-10.0* Hct-29.4* MCV-88 MCH-29.8 MCHC-33.9 RDW-14.0 Plt Ct-293 [2138-8-22] 03:42PM BLOOD WBC-9.6 RBC-3.48* Hgb-10.5* Hct-30.1* MCV-86 MCH-30.3 MCHC-35.0 RDW-14.5 Plt Ct-252 [2138-8-22] 09:17PM BLOOD PT-12.0 PTT-29.7 INR(PT)-1.0 [2138-8-29] 06:15AM BLOOD Glucose-195* UreaN-88* Creat-3.7* Na-137 K-3.5 Cl-93* HCO3-33* AnGap-15 [2138-8-22] 03:42PM BLOOD Glucose-90 UreaN-126* Creat-4.3* Na-131* K-4.5 Cl-90* HCO3-27 AnGap-19 [2138-8-22] 03:42PM BLOOD ALT-38 AST-37 CK(CPK)-274 AlkPhos-119 Amylase-34 TotBili-0.4 [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname 275] [Hospital1 18] [Numeric Identifier 90123]TTE (Complete) Done [2138-8-22] at 3:20:00 PM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] Division of Cardiothoracic [Doctor First Name ] [First Name (Titles) ] [Last Name (Titles) ] [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2069-4-18] Age (years): 69 M Hgt (in): 67 BP (mm Hg): 130/78 Wgt (lb): 165 HR (bpm): 64 BSA (m2): 1.87 m2 Indication: Preoperative assessment AVR. Increasing SOB, edema. Left ventricular function. ICD-9 Codes: 786.05, 414.8, 424.1, 424.0, 424.3, 424.2 Test Information Date/Time: [2138-8-22] at 15:20 Interpret MD: [First Name11 (Name Pattern1) 449] [Last Name (NamePattern4) ], MD Test Type: TTE (Complete) Son[Name (NI) 930]: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4587], RDCS Doppler: Full Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Adequate Tape #: 2011W032-0:00 Machine: Vivid [8-13] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 5.6 cm <= 4.0 cm Left Atrium - Four Chamber Length: 6.9 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.6 m/s Right Atrium - Four Chamber Length: 6.0 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 6.2 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 5.6 cm Left Ventricle - Fractional Shortening: 0.10 >= 0.29 Left Ventricle - Ejection Fraction: 20% >= 55% Left Ventricle - Stroke Volume: 50 ml/beat Left Ventricle - Cardiac Output: 3.22 L/min Left Ventricle - Cardiac Index: 1.72 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': 0.03 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.04 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 31 < 15 Aorta - Sinus Level: 3.1 cm <= 3.6 cm Aorta - Ascending: 4.1 cm <= 3.4 cm Aortic Valve - Peak Velocity: 3.4 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 46 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 23 mm Hg Aortic Valve - LVOT pk vel: 1.00 m/sec Aortic Valve - LVOT VTI: 16 Aortic Valve - LVOT diam: 2.0 cm Aortic Valve - Valve Area: 0.9 cm2 >= 3.0 cm2 Mitral Valve - E Wave: 1.1 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A ratio: 1.83 Mitral Valve - E Wave deceleration time: 153 ms 140-250 ms TR Gradient (+ RA = PASP): 34 mm Hg <= 25 mm Hg Pulmonic Valve - Peak Velocity: 0.8 m/sec <= 1.5 m/sec Findings LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. LEFT VENTRICLE: Normal LV wall thickness. Severely depressed LVEF. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV free wall thickness. Normal RV chamber size. Severe global RV free wall hypokinesis. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Mildly dilated ascending aorta. Focal calcifications in ascending aorta. AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Severe AS (area 0.8-1.0cm2). Moderate (2+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Mild (1+) MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.] TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid valve supporting structures. No TS. Mild to moderate [[2-9]+] TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is severely depressed (LVEF= 20 %) secondary to akinesis of the posterior wall and apex, and severe hypokinesis of the rest of the left ventricle. The right ventricular free wall thickness is normal. Right ventricular chamber size is normal. with severe global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.9 cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Electronically signed by [First Name11 (Name Pattern1) 449] [Last Name (NamePattern4) ], MD, Interpreting physician [Last Name (NamePattern4) ] [2138-8-22] 16:29 [Known lastname ],[Known firstname 275] D [Medical Record Number 90124] M 69 [2069-4-18] Pulmonary Report SPIROMETRY, DLCO Study Date of [2138-8-25] 1:11 PM SPIROMETRY 1:11 PM Pre drug Post drug Actual Pred %Pred Actual %Pred %chg FVC 2.31 3.96 58 2.39 60 +3 FEV1 1.49 2.69 55 1.63 61 +10 MMF 0.74 2.56 29 0.98 38 +32 FEV1/FVC 64 68 95 68 100 +6 DLCO 1:11 PM Actual Pred %Pred DSB 9.97 24.46 41 VA(sb) 3.10 6.28 49 HB 11.10 DSB(HB) 11.27 24.46 46 DL/VA 3.64 3.90 93 NOTES: No online pulmonary notes available. (13-096B) Brief Hospital Course: On [2138-8-22] Mr.[Known lastname 12585] was transferred from OSH to [Hospital1 18] CVICU with worsening shortness of breath, and having arrived on 100% non rebreather. He is known to the csurg service. Mr.[Known lastname 12585] is a 69yo male with severe AS, multivessel coronary artery disease and multiple co-morbidities including CKD/COPD who was recently seen by Dr.[First Name (STitle) ] in clinic for consultation regarding the need for AVR/CABG. During Mr.[Known lastname 21320] hospital admission, a large left pleural effusion was apparant on CXR. A Left thoracentesis was performed which evacuated ~2liters pale yellow fluid. His pulmonary status improved post thoracentesis, diuresis was initiated, oxygen requirement was decreased, and he was transferred to the step down unit on [8-23]. The patient was ammenable to going ahead with surgical correction/revascularization at this time. Dr.[First Name (STitle) ] fully explained the risks and benefits of proceding with surgery. Pre operative workup for risk stratification was performed. Renal was consulted for CKI. PFTs were performed. Throughout Mr.[Known lastname 21320] hospital stay, he was verbally abusive to staff and refusing safety care, such as chair indicators. He got up unassisted at night, which was witnessed by staff, and slipped onto his knee. A radiograph was done and no fracture was evident. Psychiatry was consulted regarding his agitation. On HOD# 7, he discussed with Dr.[First Name (STitle) ] his choice to refuse surgery. Social work was called to verify the patients housing situation. Elder services will be notified by social work to follow up with Mr.[Known lastname 12585]. On HOD# 8 he was discharged to home with VNA due to his refusal to have surgical intervention. Follow up with his PCP was advised. Medications on Admission: Metoprolol 25mg daily Zocor 20mg daily Lasix 40mg [Hospital1 ] Lantus 20 units daily SS regular insulin QID Spiriva 1 spray daily ( not currently taking) Valium 2mg prn sleep Protonix 40mg [Hospital1 ] Oxycodone 5mg Q4PRN for back pain ASA 81mg daily Tessalon Perles 200mg TID PRN Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:60 Tablet, Chewable(s) Refills:2 2. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:60 Tablet Extended Release 24 hr(s) Refills:2 3. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:30 Tablet(s) Refills:2 4. clonazepam 1 mg Tablet Sig: Two (2) Tablet PO DAILY 2130 (). Disp:30 Tablet(s) Refills:0 5. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). Disp:90 ML(s) Refills:0 6. prazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:30 Capsule(s) Refills:2 7. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 8. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 9. insulin glargine 100 unit/mL Cartridge Sig: One (1) Subcutaneous Q AM: 20units/resume home regimen. Disp:qs Refills:2 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: severe AS, multivessel coronary artery disease and multiple co-morbidities including CKD/COPD Secondary Medical issues: - Chronic Diastolic Congestive Heart Failure - Aortic Stenosis - Coronary Artery Disease - Chronic Renal Insufficiency ( creat 2.5) - COPD - CVA - Type II Diabetes Mellitus (IDDM) - PTSD - Chronic Pain ( fx lumbar vert.) - bilat. varicosities - osteoarthritis L shoulder/L leg - benign prostatic hypertrophy - L hand neuropathy - glaucoma L eye ( no meds) - colon polyps - recent PNA Discharge Condition: improved respiratory status s/p thoracentesis/aggressive diuresis->improved Acute on chronic kidney insufficiency Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Follow up with PCP [Last Name (NamePattern4) ] [2-9] weeks [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2138-8-29]	[ "293.0", "511.9", "584.9", "414.01", "V64.2", "428.43", "250.00", "428.0", "309.81", "564.00", "600.00", "403.90", "424.1", "V45.01", "585.9", "496" ]	icd9cm	[ [ [] ] ]	[ "34.91" ]	icd9pcs	[ [ [] ] ]	12934, 12985	9713, 11559	302, 335	13534, 13650	3297, 7797	13787, 13976	2476, 2503		11899, 12911		13006, 13513		11585, 11876				13674, 13764												7837, 9690	2518, 3278																										235, 264							363, 1316																	1533, 2208	2224, 2460
4,130	118,364	28739	Discharge summary	report	Admission Date: [2160-8-21] Discharge Date: [2160-9-3] Date of Birth: [2085-10-31] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: Cardiac Catheterization [2160-8-22] Aortic Valve Replacement with 25mm CE pericardial tissue valve and Excision of LA Mass [2160-8-25] History of Present Illness: 74M with DM, HTN, experiencing several months of increasing DOE, sometimes with interscapular pain, presented to OSH with dyspnea [8-20]. He denied CP, orthopnea, or PND. EKG revealed a fib, apparently new, and echo showed basically preserved LVEF but aortic stenosis with valve area 0.6cm2. He was transferred to [Hospital1 18] for further evaluation. Past Medical History: Hypertension, Diabetes Mellitus Social History: Lives with wife. [Name (NI) ] is retired. Quit smoking two years ago but smoked 1 ppd prior to that. Occ/social Etoh. Family History: Noncontributory Physical Exam: T96.7 BP160/90 HR70 RR16 Sat97%RA GEN: caucasian male, sitting up in bed, NAD NECK: Jugular veins 3-4cm above sternal angle, no carotid bruits CHEST: CTA B CV: irregularly irreg, s1, III/VI late peaking systolic m, no s2 ABD: obese, soft, flat, nontender, normoactive bowel sounds EXT: cool, dry, no cyanosis, clubbing, edema. PULSES: 2+ radial, 1+ DP/PT bilaterally Pertinent Results: CXR [9-1]: 1. Worsening left lower lobe consolidation and increasing small left pleural effusion. 2. Improved aeration in the right lower lobe with minimal residual atelectasis and decreased size of small left pleural effusion. Cath [8-22]: 1. Coronary arteries are normal. 2. Severe aortic stenosis. 3. Normal ventricular function. Echo [8-25]: PRE-BYPASS: The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy. Overall left ventricular systolic function is low normal (LVEF 50-55%). There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis. Trace aortic regurgitation is seen. There is moderate thickening of the mitral valve chordae. Mild to moderate ([1-28]+) mitral regurgitation is seen. POST CPB: Preserved [Hospital1 ]-ventricular systolic function. On the [Last Name (un) 27185] attempt at separation form CPB a 1.5 cm echo dense mass was seen in the LA in the region of LAA. It was pedunculated and feeely mobile. CPB was reinstituded and a large clot was removed via left atriotomy. 2nd attempt: Preserved biventricular systolic function. LAA was not visualized secondary to surgical exclusiun. A bioprosthesis is seen in the aortic posiiton, well seated and mecahnically stable. Trace AI. CXR [8-27]: Comparison is made with a prior chest radiograph dated [2160-8-25]. The patient is status post median sternotomy. Previously noted endotracheal tube, Swan-Ganz catheter, chest tubes, and mediastinal drainage tubes have been removed. There is right IJ line terminating in upper SVC. There is no definite pneumothorax. Again note is made of cardiomegaly and prominent mediastinal contours. There is bibasilar atelectasis and small effusion, unchanged since prior study. Left upper old rib fracture. [2160-8-22] 05:05AM BLOOD WBC-7.4 RBC-3.71* Hgb-12.9* Hct-35.9* MCV-97 MCH-34.9* MCHC-36.0* RDW-13.0 Plt Ct-124* [2160-8-25] 01:35PM BLOOD WBC-11.2* RBC-3.00* Hgb-10.5* Hct-30.0* MCV-100* MCH-34.9* MCHC-34.9 RDW-12.9 Plt Ct-74* [2160-8-29] 07:20AM BLOOD WBC-9.8 RBC-3.32* Hgb-11.0* Hct-32.1* MCV-97 MCH-33.2* MCHC-34.3 RDW-14.0 Plt Ct-174 [2160-8-22] 05:05AM BLOOD PT-13.0 PTT-150* INR(PT)-1.1 [2160-8-29] 07:20AM BLOOD PT-13.0 PTT-30.2 INR(PT)-1.1 [2160-8-22] 05:05AM BLOOD Glucose-168* UreaN-17 Creat-1.1 Na-137 K-4.1 Cl-100 HCO3-28 AnGap-13 [2160-8-29] 07:20AM BLOOD Glucose-159* UreaN-31* Creat-1.3* Na-136 K-4.7 Cl-102 HCO3-28 AnGap-11 [2160-8-29] 07:20AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.5 [2160-8-22] 10:24PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.010 [2160-8-22] 10:24PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-1 pH-7.0 Leuks-NEG [2160-8-30] 09:33AM BLOOD WBC-10.3 RBC-3.19* Hgb-10.7* Hct-31.5* MCV-99* MCH-33.6* MCHC-34.1 RDW-13.8 Plt Ct-249 [2160-9-1] 08:00AM BLOOD PT-14.9* PTT-55.2* INR(PT)-1.3* [2160-9-1] 08:00AM BLOOD PT-14.9* PTT-55.2* INR(PT)-1.3* [2160-8-30] 09:33AM BLOOD UreaN-28* Creat-1.3* Na-138 [2160-9-3] 07:30AM BLOOD Hct-28.9* [2160-8-30] 09:33AM BLOOD WBC-10.3 RBC-3.19* Hgb-10.7* Hct-31.5* MCV-99* MCH-33.6* MCHC-34.1 RDW-13.8 Plt Ct-249 [2160-9-3] 07:30AM BLOOD PT-22.5* PTT-90.3* INR(PT)-2.2* [2160-9-2] 07:00AM BLOOD PT-18.5* PTT-65.8* INR(PT)-1.7* [2160-9-3] 07:30AM BLOOD Glucose-102 UreaN-14 Creat-1.2 Na-135 K-4.5 Cl-100 HCO3-24 AnGap-16 Brief Hospital Course: Ms. [Known lastname 69468] was transferred from OSH to [Hospital1 18] for presumed valve surgery. She underwent a cardiac cath on [8-22] which revealed severe aortic stenosis and normal coronaries. She then underwent all pre-operative work-up. On [8-25] she was brought to the operating room where she underwent an aortic valve replacement and removal of a mass from left atrium. Please see operative report for surgical details. Following surgery she was transferred to the CSRU for invasive monitoring in stable condition. Later on op day she was weaned from sedation, awoke neurologically intact and extubated. She received blood transfusion on op day and heart rhythm converted into atrial fibrillation. Amiodarone was initiated. Heparin was started on post-op day two and continued until his INR was therapeutic on Coumadin. Also on this day his chest tubes were removed. Beta blockers and diuretics were started and he was gently diuresed towards his pre-op weight. On post-op day three he was transferred to the SDU. He remained stable over the next several days waiting for his INR to increase and become therapeutic. On post-op day seven he was found to have some sternal drainage and antibiotics were initiated. The sternal drainage resolved. His INR was 2.2 and he was ready for discharge on [2160-9-3]. Medications on Admission: lasix 20 daily, diovan 80 daily, HCTZ 25 daily, glyburide 5 daily, metoprolol 25 tid, flonase Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 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:1 5. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: 400 mg (2 tablets) daily x 1 weeks, then 200 mg (1 tablet) daily, ongoing. Disp:50 Tablet(s) Refills:0 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks. Disp:14 Tablet(s) Refills:0 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 1 weeks. Disp:28 Capsule, Sustained Release(s) Refills:0 10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:4 Tablet(s) Refills:0 11. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily): 4 mg x 2 days, then check INR [9-5] with results to Dr. [Last Name (STitle) ]. Disp:120 Tablet(s) Refills:0 12. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: Gentiva Discharge Diagnosis: Aortic stenosis s/p Aortic Valve Replacement Post-operative Atrial Fibrillation Congestive Heart Failure PMH: Hypertension, Diabetes Mellitus Discharge Condition: good Discharge Instructions: [Month (only) 116] take shower. Wash incision and gently pat dry. Do not take bath. Do not apply lotions, creams, ointments or powders to incision. Do not drive for 1 month. Do not lift greater than 10 pounds for 2 months. Please call office if you develop a fever or drainage from sternal incision. Please call to arrange all follow-up appointments. [Last Name (NamePattern4) 2138]p Instructions: Dr. [Last Name (Prefixes) ] in 4 weeks Dr. [Last Name (STitle) ] (Cardiologist) in [2-29] weeks and for coumadin follow up. Dr. [Last Name (STitle) 69469] (PCP) in [1-28] weeks Completed by:[2160-9-3]	[ "997.1", "V58.67", "E878.1", "396.2", "518.0", "V15.82", "V58.61", "427.31", "401.9", "472.0", "429.89", "398.91", "250.00" ]	icd9cm	[ [ [] ] ]	[ "88.72", "88.56", "89.68", "39.64", "39.61", "37.11", "35.21", "37.21", "34.04", "89.64", "99.04" ]	icd9pcs	[ [ [] ] ]	8188, 8226	5023, 6360	341, 485	8411, 8417	1508, 2356		1085, 1102		6504, 8165		8247, 8390		6386, 6481				8441, 8797						8848, 9076							1117, 1489																										282, 303							513, 875																	897, 930	946, 1069							2366, 5000
10,912	135,957	22864	Discharge summary	report	Admission Date: [2186-4-24] Discharge Date: [2186-5-1] Date of Birth: [2147-9-24] Sex: F Service: PSU HISTORY OF PRESENT ILLNESS: This patient is a 38-year-old female three years status post right lumpectomy and axillary dissection and chemotherapy and radiation now diagnosed with ductal carcinoma in situ in the right breast on needle localization of a mammographically-located microcalcifications here at [Hospital6 2018]. This was done on [2186-3-12]. PAST MEDICAL HISTORY: Hyperthyroidism treated with radioactive iodine and the above breast cancer described. Cesarean section. Appendectomy. PHYSICAL EXAMINATION: Vital signs: Stable. The patient was afebrile. General: She was generally a well-appearing woman in no apparent distress. Lungs: Clear to auscultation bilaterally. Heart: Regular, rate, and rhythm without murmurs, rubs, or gallops. Breasts: There was a scar from a right lumpectomy with volume loss consistent with surgery, and there were no dominant masses noted on palpation. She had no adenopathy. Extremities: No clubbing, cyanosis, or edema. HOSPITAL COURSE: The patient was admitted to the [Hospital3 ] [Hospital ] [First Name (Titles) ] [Last Name (Titles) ] for further treatment and evaluation. The plan at this point was to bring the patient to the operating room for total mastectomy. In addition she would also undergo an immediate reconstruction with possible [Last Name (un) 5884] flap that would be performed by Dr. [Last Name (STitle) ] and Dr. [First Name (STitle) 3228], a combination procedure between the breast surgery service and the plastic surgery service. On the day of admission, the patient was brought to the operating room, [2186-4-24], and the operation was performed; a skin-sparing right total mastectomy and reconstruction using an SIEA flap. The patient tolerated the procedure well and received 5.7 L of Crystalloid fluid, and her estimated blood loss was 250 ml. In the immediate postoperative period, there was noted loss of Doppler signal over the SIEA flap requiring an immediate return to the operating room. After heparin was bolused at 5000 units, a signal was retrieved, and the arm had been abducted, and temperature was elevated. The patient was intensive care unit at this time being monitored carefully, and heparin drip was started at 500 units/hour with checks of PTT to make sure that she not in a supratherapeutic range, and plan was to keep the body in room temperature, warm. In the period after this, the patient was noted to be stable, and this plan continued to be followed. On postoperative day #1, the patient was able to be extubated, and the heparin drip was continued. Also of note, the patient was able to start taking clears on postoperative day #1. Flap checks were continued at this time and were unchanged while the patient was in the intensive care unit. The patient was receiving IV cephazolin at this point for prophylactic coverage. In the early morning of postoperative day #4, the house officer was called to the bed side in regard to the patient's lost Doppler signal at the 1 a.m. check. The arm was abducted, and supportive maneuvers were made, but the flap was still noted to be pale and cool at this time. Heparin subcutaneously was started stat, and IV heparin was resumed, and Lovenox was started as well at this time while flap monitoring was continued. The plan was for possible return to the operating room for debridement versus excision of tissue that could possibly become nonviable, and on [2186-4-30], postoperative day #6, the patient was without complaint and was being monitored closely for any signs of infection or imminent sloughing of the flap. On postoperative day #7, the patient that she was feeling better, and that her pain was very well controlled, and she was tolerating a diet. On exam, the flap was explored with the Doppler, and it revealed good arterial signal and good venous signal at this time. There was some blistering and some signs of congestion, but the flap did not look to be in imminent concern at this time. Thus there was a question of whether we were dealing with epidermolysis versus deeper tissue necrosis and whether there would be need for return to the operating room due to the equivocal nature of our exam. Thus the plan at this time was to discharge the patient to home and bring back to the clinic within 48 hours for further assessment and reevaluation of the plan. The patient was continued on Keflex, continued on Lovenox, and continued on oral pain medicine. DISCHARGE INSTRUCTIONS: The patient is to call the ER or return to the surgery clinic if she experiences increased pain, swelling, bleeding, discharge from the wounds, fevers, chills, nausea or vomiting, or if there are any questions or concerns. Purulent output is to be recorded daily. The patient is to avoid driving or operating heavy machinery while taking narcotic pain medicine. The patient is to resume her home medications as she had been previously taking. FOLLOW UP: The patient is to follow-up with Dr. [First Name (STitle) 3228] within two days. She is to call his clinic to confirm this appointment. DISCHARGE MEDICATIONS: Acetaminophen 325-650 mg p.o. q.4-6 hours as needed for pain, aspirin 162 mg delayed release p.o. daily, levothyroxine 25 mcg p.o. daily, Percocet 5/325 [1-1] tab p.o. q.4-6 hours as needed for pain, ferrous sulfate 325 mg p.o. daily, Colace 100 mg p.o. b.i.d., Protonix delayed release 40 mg p.o. daily, zolpidem tartrate 5 mg p.o. hs, cephalexin 500 mg p.o. q.6 hours for 7 days. DISPOSITION: The patient is to be discharged to home and is to follow-up with Dr. [First Name (STitle) 3228] within two days. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3228], M.D. [MD Number(2) 8076] Dictated By:[Last Name (NamePattern1) 15912] MEDQUIST36 D: [2186-5-1] 10:09:31 T: [2186-5-1] 10:54:02 Job#: [Job Number 59116]	[ "V10.3", "996.79", "233.0", "244.2", "E878.8" ]	icd9cm	[ [ [] ] ]	[ "85.34", "85.89" ]	icd9pcs	[ [ [] ] ]									5250, 6042					1131, 4604			4629, 5073																						5085, 5226					665, 1113																			164, 499																	522, 642
7,422	181,432	19187	Discharge summary	report	Admission Date: [2191-8-4] Discharge Date: [2191-8-8] Date of Birth: [2115-9-8] Sex: M Service: [Location (un) ] HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old white gentleman who was in his usual state of health until the day prior to admission; when, after eating, the patient felt nauseated and vomited three times. The patient denies hematemesis. On the morning following this episode of emesis, the patient experienced a syncopal episode characterized as dizziness and lightheadedness. He awoke with emergency medical technicians putting him in an ambulance. He denies a postictal state. He denied loss of bowel or bladder continence. The patient was taken to [Hospital 26200] Hospital where a head computed tomography demonstrated a subdural and subarachnoid hemorrhage. He was then transferred to [Hospital1 1444] for evaluation by Neurosurgery. In the Emergency Department, the patient vomited bright red blood one time. In the Emergency Department, the patient received fresh frozen plasma, activated factor VII, and two units of packed red blood cells. Of note, the patient had a mechanical aortic valve for which he was taking Coumadin and was found to supratherapeutic on admission. PAST MEDICAL HISTORY: (Past medical history is significant for) 1. Aortic valve replacement in [2187]. 2. Coronary artery disease; status post 4-vessel coronary artery bypass graft in [2187]. 3. Hypercholesterolemia. 4. Benign prostatic hypertrophy. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: PHYSICAL EXAMINATION ON PRESENTATION: On admission physical examination the patient's temperature was 99 degrees Fahrenheit, his heart rate was 123, his oxygen saturation was 100% on three liters, and his blood pressure was 134/76. In general, the patient was well-appearing, in no apparent distress. Head, eyes, ears, nose, and throat examination revealed pupils were equal, round, and reactive to light. The mucous membranes were slightly dry. The neck was supple. Cardiovascular examination revealed a regular rate and rhythm. A 3/6 systolic murmur at the left upper sternal border and a metallic click. Pulmonary examination revealed the lungs were clear to auscultation bilaterally. Abdominal examination revealed the abdomen was soft, nontender, and nondistended. Normal active bowel sounds. Extremity examination revealed no cyanosis, clubbing, or edema. Good distal pulses. Neurologic examination revealed cranial nerves II through XII were intact. Motor strength was [5-16] bilaterally in all muscle groups. Sensation was intact throughout. Reflexes were 2+ bilaterally throughout. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on admission were notable for a white blood cell count of 11.6, his hematocrit was 20.4, and his platelets were 257. Chemistry-7 was notable for a blood urea nitrogen of 63 with a creatinine of 0.7. The patient's INR was 5 with a partial thromboplastin time of 33. Urinalysis showed trace ketones. Urine culture was negative. PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed a right bundle-branch block with a rate of 120 (sinus rhythm). CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. INTRACRANIAL BLEED ISSUES: Neurosurgery was consulted. The patient's anticoagulation was reversed with a goal INR of less than 1.3 and platelets of greater than 100. Anticoagulation was held while the intracranial hemorrhage was further worked up. A head computed tomography was done. There was no significant change compared to the study done at the [Hospital 26200] Hospital. The computed tomography showed bilateral low density subdural collections with the left greater than the right. There was also an area of hemorrhage in the inferior left frontal lobe. There was a question of whether the bleed represented an acute or chronic process. The patient was maintained on every 1-hour neurologic checks. The patient had a computed tomography angiogram which showed no evidence of aneurysm. The patient also had a magnetic resonance angiography which also did not show any evidence of aneurysm. As the patient was stable with no active bleeding, he was transferred out the Medical Intensive Care Unit and onto the floor. Neurosurgery did not feel it necessary for intervention at this time as the patient was stable. 2. GASTROINTESTINAL BLEED ISSUES: The patient was initially placed on Protonix and monitored for repeat hematemesis. The Gastrointestinal Service was consulted. An esophagogastroduodenoscopy was done which showed [Doctor Last Name 15532] esophagus and ulcer at the gastroesophageal junction, changes in the prepyloric region compatible with gastritis, and changes in the duodenal bulb compatible with duodenitis. As per recommendations from the Gastrointestinal Service, the patient was continued on Protonix 40 mg by mouth twice per day, and the patient would need a follow-up esophagogastroduodenoscopy with a biopsy in four to six weeks. No active bleeding was seen during this esophagogastroduodenoscopy. During the rest of the hospital admission, the patient remained stable with no further evidence of active gastrointestinal bleeding, and his hematocrit remained stable. 3. ANTICOAGULATION ISSUES: The patient required anticoagulation for an artificial aortic valve. However, due to the presence of intracranial hemorrhage, anticoagulation with Coumadin was held initially upon admission. Neurosurgery was consulted for recommendations regarding restarting the anticoagulation. As per the Neurosurgery Service, it was decided to hold off any anticoagulation for two months; at which point the patient was instructed to follow up with his local neurosurgeon for reassessment of restarting his anticoagulation. 4. CORONARY ARTERY DISEASE ISSUES: The patient was continued on a statin. He was started on atenolol 25 mg by mouth every day. Aspirin was not given the patient secondary to his intracranial bleeding. The patient was ruled out for a myocardial infarction during his hospital admission. CONDITION AT DISCHARGE: Condition on discharge was stable. The patient was afebrile and hemodynamically stable. His hematocrit was stable with no evidence of gastrointestinal bleeding. The patient's mental status was at baseline. He was ambulating without difficulty and tolerating a by mouth diet. MEDICATIONS ON DISCHARGE: 1. Protonix 40 mg by mouth twice per day. 2. Lipitor 10 mg by mouth once per day. 3. Flomax 0.4 mg by mouth at bedtime. 4. Colace 100 mg by mouth twice per day. 5. Atenolol 25 mg by mouth once per day. DISCHARGE DIAGNOSES: 1. Subdural hematoma. 2. Subarachnoid hemorrhage. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with his local neurosurgeon upon returning to his home in [State 108]. 2. The patient was also instructed to follow up with a gastroenterologist locally in [State 108] for a repeat esophagogastroduodenoscopy in four to six weeks. 3. The patient was instructed not to take any anticoagulation medications such as aspirin or Coumadin for two months after discharge; or as advised by his local neurosurgeon. 4. The patient was given a copy of head computed tomography report and esophagogastroduodenoscopy report to take with him for local followup. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 2506] Dictated By:[Name8 (MD) 5709] MEDQUIST36 D: [2191-9-26] 16:45 T: [2191-9-28] 09:54 JOB#: [Job Number 52324]	[ "530.82", "530.2", "780.2", "V58.61", "V43.3", "531.90", "852.26", "285.1", "E885.9" ]	icd9cm	[ [ [] ] ]	[ "45.16" ]	icd9pcs	[ [ [] ] ]								6682, 6735				6453, 6661	1586, 3224							6768, 7630																						3258, 6133				6148, 6427																	175, 1257																	1280, 1559
10,916	183,540	50583	Discharge summary	report	Admission Date: [2186-12-13] Discharge Date: [2186-12-21] Date of Birth: [2105-2-5] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2840] Chief Complaint: Cough, GIB Major Surgical or Invasive Procedure: None. History of Present Illness: 81 y/o female with hx of type 2 DM, HTN, hypercholesterolemia, and iron deficiency anemia admitted through the ED on [12-13] with PNA, anemia, and hypoglycemia. The patient reports that she has not been feeling well since late [2186-9-27]. Since that time, she has had ongoing body aches and cough. In addition, she notes recent onset of epigastric pain which she attributed to "heart burn". In the ED, the patient was found to be anemic with a Hct of 21.1 (baseline Hct in the high 20s to low 30s). Her stool was brown but guaic positive. She was transfused 2u of pRBC and GI consulted. Given 10 mg of vitamin K to reverse her anticoagulation (for atrial fib). CXR noted for PNA and started on azithromycin and ceftriaxone. . In the ED, mistakenly thought that the patient's glucose was 500 (this was acutually her platelet count) and she was given 10 units of humalog insulin. Patient's glucose was 63. She was treated with 1 amp of D50 then started on a D10 drip. She was then admitted to the MICU for close monitoring of her blood sugars. . In the MICU, the patient's FS were monitored Q1H and then spaced out to Q2H. These remained stable. The patient was initially covered with a sliding scale insulin then restarted on her home dose of 70/30. It was felt that the patient's PNA was not clear on CXR but treatment with ceftriaxone and azithromycin was continued. The team considered obtaining a CT but this was not persued. GI was consulted but plans to do an outpatient EEG and colonoscopy if the patient remains stable. Her coumadin was held in the MICU given the guiac positive stools and decreased Hct. Past Medical History: 1) Type 2 diabetes mellitus since [2175] 2) Osteoarthritis of left knee, status post R TKR [2184-1-1] 3) Hypertension 4) Breast cancer status post R mastectomy in [2167] 5) Thyromegaly/hypothyroidism 6) Carpal tunnel syndrome 7) Hypercholesterolemia 8) Gastroesophageal reflux disease 9) Paroxysmal Atrial Fibrillation, on coumadin 10) Post nasal drip 11) Chronic renal insufficiency, baseline 1.2-1.7. 12) Iron deficiency anemia Social History: Lives in a single apartment where she has been for 27 years. Her son lives close by. She used to smoke but quit about 40 years ago. She doesn't drink or use IV drugs. Family History: No CAD. "Everyone has diabetes." Physical Exam: 99.4 Tm- 99.9 130/60 (130-144/60) 73 24 94% RA FS: 165-206-136 Gen- Pleasant elderly lady sitting up in bed. Alert. NAD. HEENT- NC AT. MMM. No lesions in the oropharynx. Cardiac- Irreg irregular. Normal S1 S2. S4. No m,r,g. Pulm- Decreased effort but CTAB. No wheezes, rales, or rhonchi. Abdomen- Soft. Mild diffuse tenderness. No rebound or gaurding. ND. Positive bowel sounds. Guiac positive during admission. Extremities- No c/c/e. Pertinent Results: [2186-12-13] 11:00AM BLOOD WBC-9.2 RBC-3.20* Hgb-6.4# Hct-21.1 MCV-66* MCH-20.2# MCHC-30.5 RDW-20.8* Plt Ct-512# [2186-12-14] 03:11AM BLOOD WBC-10.4 RBC-3.81 Hgb-8.5* Hct-26.9* MCV-71* MCH-22.3* MCHC-31.6 RDW-21.3* Plt Ct-440 [2186-12-15] 05:35AM BLOOD WBC-10.5 RBC-4.15* Hgb-9.3* Hct-29.1* MCV-70* MCH-22.4* MCHC-32.0 RDW-21.9* Plt Ct-463* [2186-12-21] 05:35AM BLOOD WBC-9.3 RBC-3.94* Hgb-8.9* Hct-28.9* MCV-73* MCH-22.6* MCHC-30.8* RDW-23.0* Plt Ct-361 [2186-12-13] 11:00AM BLOOD Neuts-69 Bands-0 Lymphs-23 Monos-5 Eos-1 Baso-1 Atyps-1* Metas-0 Myelos-0 NRBC-3* [2186-12-13] 11:00AM BLOOD PT-25.2* PTT-29.3 INR(PT)-2.5* [2186-12-14] 03:11AM BLOOD PT-19.8* PTT-27.8 INR(PT)-1.9* [2186-12-18] 05:30AM BLOOD PT-12.4 PTT-26.5 INR(PT)-1.1 [2186-12-21] 05:35AM BLOOD PT-12.3 PTT-29.7 INR(PT)-1.1 [2186-12-13] 11:00AM BLOOD Glucose-63* UreaN-27* Creat-1.7* Na-140 K-4.8 Cl-105 HCO3-25 AnGap-15 [2186-12-17] 09:07AM BLOOD Glucose-160* UreaN-27* Creat-1.4* Na-140 K-4.4 Cl-103 HCO3-28 AnGap-13 [2186-12-21] 05:35AM BLOOD Glucose-109* UreaN-14 Creat-1.0 Na-140 K-4.1 Cl-104 HCO3-25 AnGap-15 [2186-12-13] 11:00AM BLOOD ALT-12 AST-26 CK(CPK)-187* AlkPhos-77 Amylase-78 TotBili-0.3 [2186-12-13] 11:00AM BLOOD Lipase-46 [2186-12-13] 11:00AM BLOOD CK-MB-3 cTropnT-<0.01 [2186-12-14] 03:11AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.4 [2186-12-18] 05:30AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.2 [2186-12-21] 05:35AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.7 [2186-12-13] 11:00AM BLOOD calTIBC-434 Hapto-134 Ferritn-13 TRF-334 [2186-12-20] 05:25AM BLOOD CEA-4.1* . CHEST (PA & LAT) [2186-12-13] 11:36 AM Left lower lobe pneumonia. . ECG Study Date of [2186-12-13] 11:18:12 AM Probable ectopic atrial rhythm or accelerated junctional rhythm. Modest low amplitude T waves with prolonged Q-Tc interval - may be in part drug/metabolic/electrolyte effect. Since previous tracing of [2186-8-20], ectopic atrial rhythm present and ventricular ectopy not seen. . CT ABDOMEN W/O CONTRAST [2186-12-20] 8:32 PM 1. Circumferential mass lesion in the proximal ascending colon correlating with the patient's colonoscopy findings and concerning for malignancy. There is no proximal or distal lymphadenopathy. There is no evidence of obstruction. 2. Multiple liver lobe lesions as detailed above. These are not completely characterized on this non-contrast study and correlation with MRI or multiphasic CT is recommended. . CHEST (PRE-OP PA & LAT) [2186-12-20] 9:07 PM The cardiac silhouette is grossly enlarged. The mediastinal contour is normal. Bilateral hila are full, with pulmonary vascular redistribution. A streaky opacity within the left lung base is not significantly changed since prior exam. The surrounding soft tissue and osseous structures are stable. IMPRESSION: 1. Persistent left lower lobe opacity. 2. Mild/moderate CHF. Brief Hospital Course: 81 y/o female with PMH significant for type 2 DM, HTN, hypercholesterolemia, and iron deficiency anemia admitted on [12-13] with PNA and hypoglycemia, evaluated for GIB with EGD and colonoscopy and found to have malignant lesion in colon, to be followed by surgery outpatient for possible resection. . # GI Malignancy: Pt had colonoscopy and EGD on [2186-12-20] and was found to have polyps in the rectum (biopsy), 3cm ulcerated malignant appearing mass in the ascending colon (biopsy), otherwise normal colonoscopy to cecum. EGD with normal esophagus, stomach, and duodenum. Pt had CT abd in [7-/2186] for abdominal pain which revealed normal bowel and no enlarged lymph nodes. CT abdomen w/ contrast for staging during current admission revealed cratered lesion in ascending colon characteristic of malignancy, without enlarged lymph nodes. Pt evaluated with pre-op CXR which revealed mild CHF and persistent LLL opacity. As pneumonia had not resolved, pt will followup with Dr. [Last Name (STitle) 32924] from [Hospital1 18] Surgery outpatient within 1 week. Consultation by surgery with impression that she would be a candidate for operation. Colon biopsy path pending on discharge. . # Hypoglycemia: Acute issue that necessitated patient's admission to the MICU. She received 10 units of humalog insulin as her platelet and glucose counts were mistaken for each other. The patient was briefly on a D10 drip and required Q1H then Q2H FS. She has now recovered and is back on her regular home insulin regimen. Blood sugars remaining stable, pt asymptomatic. . # LLL PNA: Likely community acquired PNA. Retrocardiac oppacity on her CXR. Sats stable on RA. Completed azithromycin x 7 days. Symptomatic rx with expectorant, lozenges, nebs prn. Monitor oxygen sats at rest and with ambulation. Pt remained afebrile without leukocytosis. . # Iron deficiency anemia/Chronic GIB: Pt with iron deficiency anemia and guiac positive stools. No past EEG or colonoscopy. Pt transfused with 3u pRBC during hospital course. No persistent BRBPR. Hct remaining stable post transfusion and pt hemodynamically stable. Tolerating PO intake. PPI [Hospital1 ]. Held coumadin pending GI outpatient eval on [12-20]. Continued on ferrous sulfate 325 mg daily. Bowel regimen with colace, senna. . # Atrial fib Holding coumadin, cont beta blocker. INR intially supratherapeutic and reversed with FFP and vitamin K. Now within normal range as off coumadin pending GI workup. Continue beta blocker for rate control. Coumadin held during hospital course and restarted on discharge, pending future surgery. . # CRI Baseline creatinine of 1.4-1.6. Pt is currently at her baseline. Foley DC'd post admission to medicine floor. Adequate urine output. UA negative, though with large number of RBCs likely from traumatic foley. Avoided nephrotoxic drugs. Monitor UOP and renal function. Consider switching from atenolol to metoprolol outpatient. . # Code status: Full code . # DISPO: Followup with [Hospital1 18] Surgery and PCP [Name Initial (PRE) ]. Regular INR checks by VNA to ensure within therapeutic range. Medications on Admission: Celexa 20 mg daily Enalapril 5 mg daily Insulin NPH 50 qAM, 12u qPM Levothyroxine 50 mcg daily Aspirin 81 mg daily Warfarin 5mg qd Lipitor 10 mg daily Atenolol 25 mg daily Amlodipine 10 mg daily Tessalon perles tid Protonix 40 mg daily Levofloxacin 250 mg daily Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [11-28] Puffs Inhalation Q6H (every 6 hours) as needed. Disp:1 inhalers Refills:2 7. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) as needed for sore throat. Disp:30 Lozenge(s) Refills:0 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 9. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 12. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. Disp:1 bottle Refills:0 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 15. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:2 inhalers Refills:2 17. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 18. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: 50 units Subcutaneous qAM. Disp:1 pen Refills:2 19. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: 12 units Subcutaneous qPM. Disp:1 pen Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: PRIMARY DIAGNOSES: 1. Left lower lobe pneumonia 2. Malignant-appearing lesion in ascending colon . SECONDARY DIAGNOSES: 1. Type 2 DM- Diagnosed [2175]. 2. Osteoarthritis of the left knee 3. HTN 4. Breast CA s/p R mastectomy- [2167] 5. Thyromegaly 6. Hypthyroidism 7. Carpal tunnel syndrome 8. Hypercholesterolemia 9. Parosxysmal atrial fib- Pt is anticoagulated on coumadin. 10. Post nasal drip 11. Chronic renal insufficiency- Baseline creatinine is 1.4 to 1.7. 12. Iron deficiency anemia- Baseline Hct is high 20s to low 30s. 13. S/P right total knee replacement- [12/2183] Discharge Condition: Stable. Discharge Instructions: You were admitted for a pneumonia and were also found to have a low blood count. You were evaluated by the GI specialists and were found to have a lesion in your colon concerning for malignancy. You were evaluated by surgery service who recommended outpatient followup. Your blood thinner, coumadin, was held while in the hospital and was restarted on discharge. You were treated with antibiotics for the pneumonia. . Please take all medications as prescribed. Call your PCP or return to the ED if you experience shortness of breath, chest pain, notice blood in your bowel movements, experience dizziness/lightheadedness. . It is very important that you followup with [Hospital1 18] Surgery to discuss management plan and need for surgery. Followup Instructions: You will resume coumadin at home, please have INR checked before Monday by VNA service. . You have an appointment at [Hospital1 18] Surgery Clinic: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD Date/Time:[2186-12-28] 10:45 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4853], M.D. Date/Time:[2187-1-9] 2:00 Please followup with your PCP [Name Initial (PRE) 176] 1 week, call number below to make an appointment: PCP: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 719]	[ "153.6", "403.90", "V10.3", "244.9", "211.4", "280.0", "272.0", "V58.61", "427.31", "585.9", "578.9", "250.80", "486" ]	icd9cm	[ [ [] ] ]	[ "45.25", "45.16", "99.04" ]	icd9pcs	[ [ [] ] ]	11470, 11527	6078, 9197	327, 335	12159, 12169	3157, 6055	12961, 13559	2651, 2685		9509, 11447		11548, 11647		9223, 9486				12193, 12938													2700, 3138			11668, 12138																							277, 289							363, 1985																	2007, 2451	2467, 2635
22,093	145,386	22040	Discharge summary	report	Admission Date: [2167-10-26] Discharge Date: [2167-10-28] Date of Birth: [2167-10-26] Sex: F Service: NB HISTORY OF PRESENT ILLNESS: Baby girl [Known lastname 57666] is the twin number 1, 2315 gram product of a 35 and [3-8]-week gestation [Month/Day (4) ] to a 39-year-old G5 P2 mother with prenatal screens blood type O positive, antibody negative, RPR nonreactive, rubella immune, hepatitis B negative, and GBS unknown. Mother is from [Country 2559]. She has had 3 first trimester miscarriages. She has a prothrombin G mutation, is hypothyroid, and has thalassemia minor. This was an IUI twin pregnancy, which was electively reduced from triplets. On her preterm labor at 24-5/7 weeks, at which time, she received betamethasone. She was also treated with Lovenox and baby aspirin during this pregnancy. This baby was [Name2 (NI) ] by [Name (NI) 32007] secondary to unstoppable preterm labor with breech presentation and thus twin. Her Apgar scores were 7 at 1 minute and 8 at 5 minutes of life. ADMISSION PHYSICAL EXAMINATION: Birth weight was 2315 grams, length was 46.5 cm, and head circumference was 33 cm. This corresponds to 58th percentile for weight, 58th percentile for length, and 25th percentile for head circumference. In general, she was an active preterm female in mild respiratory distress. HEENT examination revealed an anterior fontanel that was open and flat, red reflexes present bilaterally, and an intact palate. Her chest examination showed moderate air movement with intercostal retractions and some grunting. Her heart has regular rate and rhythm without murmur. Her abdomen was soft with active bowel sounds and no masses. Her extremities are warm and well perfused. Her spine showed no sacral [Hospital1 ] or dimples. Her anus was patent. Her hips were stable. Her clavicles were intact. Neurologically, she had normal tone and activity. HOSPITAL COURSE: 1. Respiratory. Initially baby girl [Name (NI) 57666] had some mild respiratory distress including grunting and retractions. She transitioned well over the first 1 to 2 hours of life and has been in room air throughout her hospitalization. She has never had any episodes of apnea or bradycardia. 2. Cardiovascular. Initially baby girl [Name (NI) 57666] had borderline low blood pressures with mean arterial pressures in the range of 30 to 36. She received 2 normal saline boluses over the first 6 hours of life, after which her blood pressure stabilized and well perfused for gestational age for the remainder of her hospitalization. 3. Fluids, electrolytes, and nutrition. Initially baby girl [Name (NI) 57666] was started on IV fluid of D10W at 80 cubic centimeters per kilogram per day. Her first dextrose sticks was 45, with the correction of 295 after IV fluids and remained stable thereafter. She initiated breast- feeding at about 12 hours of life and was able to breast- feed well. On the day prior to transfer from the Neonatal Intensive Care Unit, she took 80 cubic centimeters per kilogram per day of Similac-20 in addition to breast- feeding well. She has voided and stooled normally throughout her stay. Her electrolytes at 24 hours were normal. 4. Hematology. Baby girl [Known lastname 57666]'s initial hematocrit was 51.9 percent with normal platelets of 315,000. 5. Infectious disease. Secondary to sepsis risk factors including preterm labor and unknown GBS status, baby girl [Known lastname 57667] CBC with differential and blood culture were drawn and was begun on ampicillin and gentamicin. Her CBC was reassuring with a white count of 14,100 including 29 polys and 0 bands. Her culture was negative, so ampicillin and gentamicin were discontinued at 48 hours. 6. GI. Baby girl [Known lastname 57666]'s first bilirubin was 5.4 at 24 hours of life. Bilirubin on day of life 2, the day of transfer to the new [Known lastname ] nursery was 8.9 with the direct component of 0.3. She has not received any further therapy. CONDITION AT TRANSFER: Good. DISCHARGE DISPOSITION: Transfer to New [Known lastname ] Nursery. PRIMARY PEDIATRICIAN: To be chosen by parents prior to discharge. CARE/RECOMMENDATIONS: 1. At the time of transfer, baby girl [Name (NI) 57666] is breast- feeding ad lib with supplementation of Similac-20 as needed. 2. She is on no medications. 3. She has not yet had car seat position screening, but should have this prior to discharge, as she is less than 37-week gestation. 4. State new [Name (NI) ] screen should be sent prior to discharge as per new [Name (NI) ] nursery protocol. 5. Hepatitis B vaccination should be given prior to discharge as per new [Name (NI) ] nursery protocol. DISCHARGE DIAGNOSES: 1. Prematurity at 35-3/7 weeks gestation. 2. Suspected sepsis, ruled out. 3. Hypotension, resolved. Reviewed By: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 53043], [MD Number(1) 53044] Dictated By:[Last Name (NamePattern1) 57619] MEDQUIST36 D: [2167-10-28] 16:47:43 T: [2167-10-29] 02:51:44 Job#: [Job Number 57668]	[ "V31.01", "774.2", "765.18", "765.28", "V29.0", "779.3", "796.3", "V05.3" ]	icd9cm	[ [ [] ] ]	[ "99.55", "99.15" ]	icd9pcs	[ [ [] ] ]	4197, 4873							4894, 5260						1966, 4173																														1096, 1949																			167, 1073
73,770	179,568	9760+56067	Discharge summary	report+addendum	Admission Date: [2146-8-7] Discharge Date: [2146-8-20] Date of Birth: [2066-7-17] Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 2836] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: Intubation on [2146-8-7] History of Present Illness: Mr. [Known lastname 32913] is an 80-year-old male who presented from rehabwith respiratory distress. This was in the setting of recent hospitalization ([141-12-2]) during which he was treated for a florid urinary tract infection, acute kidney injury, J-tube clogging, severe fluid imbalances, and intubation for respiratory distress in the context of a LLL PNA which grew out E.coli. All this took place after a duodenal perforation s/p a laparoscopic cholecystectomy at an OSH on [2146-6-2], after which he was brought to [Hospital1 18] for repair of duodenal injury, placement of lateral duodenostomy tube, feeding jejunostomy tube, and PTBD (6/[2146]). Past Medical History: Past Medical History: HTN, prostate CA, duodenal ulcer Past Surgical History: partial gastrectomy with BII reconstruction, prostatectomy with bilateral inguinal node dissection, laparoscopic cholecystectomy Social History: He lives in a long term care facility. He does not drink alcohol, and has not smoked for 20 years. Family History: non-contributory Physical Exam: ADMIT EXAM: Vitals: T =100.4, HR = 109, RR = 20, O2Sat = 100% NRB, BP = 132/74 General: Sedated, intubated, thin and ill appearing white male HEENT: Sclera anicteric,Pupils of 5 minimally reactive, moving eyes around, not blinking very much but blinks to light shinning in the, Neck: supple, JVP not elevated when recumbent at 0 deg no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Coarse breathsounds at the left base compared to the right Abdomen: soft, midline scar is well healed. Drains on left appear to be intact, with multiple bags full of dark yellow/[Location (un) 2452] fluid. No erythema of the skin surrounding them. Hypoactive bowel sounds but normal pitch. Ext: warm, well perfused, 2+ pulses DP pulses bilaterally no clubbing, cyanosis or edema Neuro: Unable to assess as patient is sedated and intubated DISCHARGE EXAM: Vitals: 98.2 97.8 89 113/56 16 99%RA General: In no distress, thin appearing male, interactive upon stimulation HEENT: anicteric sclera, PERRLA CV: RRR, +S1/S2, no m/r/g Lungs: Sparse coarse breath sounds diffusely, otherwise CTAB Abdomen: soft, well-healed incision. Drains x4 intact. +BS, NT, ND, no r/r/g Ext: warm, well perfused, 2+ distal pulses Pertinent Results: IMAGING: 1) CHEST (PORTABLE AP) ([2146-8-7]): An endotracheal tube is positioned 4.2 cm above the level of the carina. A nasoenteric catheter courses below the diaphragm with the tip in the stomach. A left PICC is in unchanged position terminating in the mid SVC. There is consolidation within the left lung base. which appears similar to prior examination and likely reflects atelectasis or resolving pneumonia. No new confluent opacity is identified. There is no pneumothorax. Blunting of the bilateral costophrenic angles is unchanged from prior and likely suggests possible small effusions. There is no overt interstitial edema. Cardiomediastinal and hilar contours are within normal limits. IMPRESSION: Expected position of support devices. No pneumothorax. Persistent retrocardiac opacity possible atelectasis or resolving pneumonia. Probable small bilateral pleural effusions. 2) BILAT LOWER EXT VEINS ([2146-8-7]): [Doctor Last Name ]-scale and color Doppler images of bilateral common femoral, superficial femoral, deep femoral, popliteal and calf veins demonstrate normal flow, compressibility and response to augmentation. IMPRESSION: No evidence of deep venous thrombosis in bilateral lower extremities. 3) CT HEAD W/O CONTRAST ([2146-8-7]): There is no evidence of hemorrhage, edema, mass effect or infarction. Prominence of the ventricles and sulci is compatible with age-related global atrophy, unchanged. There is mild left cavernous carotid artery calcification. No osseous lesions are seen. There are mucosal retention cysts and mucosal thickening within the maxillary sinuses. A small amount of aerosolized secretions are seen within the left sphenoid sinus. The mastoid air cells are grossly clear. IMPRESSION: Age appropriate volume loss and mild carotid calcification. Otherwise normal study. No evidence of acute intracranial process. 4) CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST ([2146-8-7]): Wet read- bibasilar atelectasis, left greater than right. given history, an aspiration is certainly possible. dense atherosclerotic calcifications. hypodense vascular space consistent with anemia. unchanged right upper lobe pulmonary nodules. known multiple biliary drains and stent from prior procedure with bile leak. scattered free fluid however no focal collection or evidence of abscess. MICRO/PATH: GRAM STAIN (Final [2146-8-7]): >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [2146-8-7]): TEST CANCELLED, PATIENT CREDITED. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. FUNGAL CULTURE (Preliminary): GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS. Specimen is only screened for Cryptococcus species. New specimen is recommended ADMIT LABS: [2146-8-7] 12:25PM BLOOD WBC-16.2* RBC-3.03* Hgb-9.0* Hct-29.5* MCV-97 MCH-29.8 MCHC-30.6* RDW-16.8* Plt Ct-738* [2146-8-7] 12:25PM BLOOD Neuts-66.5 Lymphs-22.6 Monos-2.4 Eos-7.8* Baso-0.7 [2146-8-7] 12:25PM BLOOD PT-11.5 PTT-30.5 INR(PT)-1.1 [2146-8-7] 12:25PM BLOOD Plt Ct-738* [2146-8-7] 12:25PM BLOOD Glucose-890* UreaN-68* Creat-2.3* Na-134 K-5.6* Cl-105 HCO3-18* AnGap-17 [2146-8-7] 12:25PM BLOOD ALT-12 AST-29 AlkPhos-196* TotBili-0.5 [2146-8-7] 12:25PM BLOOD Albumin-2.6* [2146-8-7] 03:04PM BLOOD Calcium-8.8 Phos-3.8 Mg-1.9 [2146-8-7] 02:17PM BLOOD Type-ART Temp-38.0 Tidal V-450 FiO2-100 pO2-159* pCO2-41 pH-7.28* calTCO2-20* Base XS--6 AADO2-513 REQ O2-86 Intubat-INTUBATED [2146-8-7] 12:31PM BLOOD Lactate-1.0 DISCHARGE LABS: [2146-8-18] 05:39AM BLOOD WBC-9.4 RBC-2.63* Hgb-8.2* Hct-24.5* MCV-93 MCH-31.0 MCHC-33.2 RDW-17.1* Plt Ct-628* [2146-8-18] 05:39AM BLOOD Plt Ct-628* [2146-8-18] 05:39AM BLOOD Glucose-108* UreaN-69* Creat-1.5* Na-131* K-4.1 Cl-105 HCO3-18* AnGap-12 [2146-8-18] 05:39AM BLOOD ALT-13 AST-36 AlkPhos-313* TotBili-0.4 DirBili-0.2 IndBili-0.2 [2146-8-18] 12:50PM BLOOD Vanco-19.2 Brief Hospital Course: 80 year old male s/p CCY complicated by duodenal perforation with multiple drains in place and recently discharged after prolonged hospital course where he was treated for pan sensitive Ecoli pneumonia to rehab who presents with acute respiratory distress and leukocytosis. On [2146-8-7]: The patient was tachypnic on admission and hypoxemic with increased oxygen requirement. He was intubated, and his CXR post-intubation revealed stable infiltrates bilaterally. He was admitted to the medical ICU. ABG revealed a non-anion gap acidosis without appropriate respiratory compensation. CT Chest revealed on PNA, and LE ultrasound revealed no DVT. He was continued on TPN. He was started on vancomycin, cefipime, and flagyl empirically given a leukocytosis without a left shift and no obvious initial course. Blood and urine cultures were obtained. CT abdomen and CT head were obtained. On [2146-8-8]: The patient remained intubated and sedated, on CMV/Assist settings. His care was transferred to the Surgical ICU team. He was continued on TPN, and remained NPO, with nothing but medication by J tube. Antibiotics as stated above, were continued. On [2146-8-9]: The patient's ventilator settings were adjusted to CPAP/PS. He was continued on TPN, kept NPO, with nothing but medication by J tube. Antibiotics were continued, but adjusted to include only vancomycin and cefipime. On [2146-8-10]: The patient was successfully extubated on this day. He was continued on TPN, and kept NPO, with nothing by medication by J tube. On this day, he was able to spend much time sitting in a chair, and was noted to be conversational and interactive. Antibiotics were continued. Planning was begun to transfer him to the regular floor. On [2146-8-11]: The patient was kept NPO, and continued on TPN. On this day, he was transferred back to the floor for his continued recovery. He continued to look well. Antibiotics were continued. On [2146-8-12]: The patient was kept NPO, on TPN, with foley catheter and PTBD, T Tube, [Doctor Last Name 406] drain in place. Physical Therapy continued to work with the patient. He was continued on antibiotics (vancomycin and cefepime). On [2146-8-13]: The patient was kept NPO, on TPN, with all catheters and drains in place, and antibiotics runing. On [2146-8-14]: All prior drains were maintained. The patient remained NPO, on TPN. He continued to work with physical therapy. Dispo planing to rehab was initiated. On [2146-8-15]: All drains as above (PTBD, T Tube, foley, [Doctor Last Name 406] drain) were maintained. The patient remained NPO, on TPN, and antibiotics. Thereafter, the patient continued to recover well, with no remarkable events. His drains were all maintained, and he remained NPO, on TPN, and the above stated antibiotics. These antibiotics are to be continued until [2146-8-21]. The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. The patient's complete blood count was examined routinely. he patient's white blood count and fever curves were closely watched for signs of infection. The patient received subcutaneous heparin and venodyne boots were used during this stay; he was seen by and worked with Physical Therapy. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was on TPN, with nothing by J tube except medication. He is to receive IV antibiotics (cefipime and vancomycin) until [2146-8-21]. Discharge planning to an extended care facility was made, and thorough follow-up instructions were provided. Medications on Admission: 1. Acetaminophen IV 1000 mg IV Q6H:PRN pain 2. Carbidopa-Levodopa (25-100) 1 TAB NG TID please crush and give via j-tube with 60cc water to avoid j-tube clogging 3. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 4. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 5. Heparin 5000 UNIT SC TID 6. Insulin SC Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB 8. Pantoprazole 40 mg IV Q24H Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain 2. Carbidopa-Levodopa (25-100) 1 TAB PO TID via j-tube 3. CefePIME 2 g IV Q24H 4. Heparin 5000 UNIT SC TID 5. Insulin SC Sliding Scale Fingerstick Q4h Insulin SC Sliding Scale using REG Insulin 6. Octreotide Acetate 200 mcg SC Q8H 7. Ondansetron 4 mg IV Q8H:PRN nausea 8. Pantoprazole 40 mg IV Q24H 9. Senna 1 TAB PO BID:PRN constipation 10. Vancomycin 750 mg IV Q 24H 11. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 12. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 13. Heparin Flush (10 units/ml) 10 mL IV PRN PICC Flush 14. 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. 15. 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. 16. 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 105] - [Location (un) 86] Discharge Diagnosis: Respiratory distress, in setting of recent hospitalization ([2146-7-14]) during which he was treated for a florid urinary tract infection, acute kidney injury, J-tube clogging, severe fluid imbalances, and intubation for respiratory distress in the context of a LLL PNA which grew out E.coli. All this took place after a duodenal perforation s/p a laparoscopic cholecystectomy at an OSH on [2146-6-2], after which he was brought to [Hospital1 18] for repair of duodenal injury, placement of lateral duodenostomy tube, feeding jejunostomy tube, and PTBD (6/[2146]). Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Mr. [Known lastname 32913] was admitted to the surgery service at [Hospital1 18] for evaluation and management of respiratory distress. He has recovered well, and is now safe to return to an extended care facility to complete his recovery with the following instructions: Please resume all regular medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please allow patient to get plenty of rest, continue to ambulate as tolerated, and continue TPN. Please do NOT administer any tube feesd, the patient is to receive only CRUSHED Cinemet by J tube. Please follow-up with surgeon and Primary Care Provider (PCP) as advised. Care for Drains: Please look at the sites every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). Maintain suction of the bulb drains, and allow the bag-drains to hang to gravity. Note color, consistency, and amount of fluid in the drain. Call the doctor or nurse practitioner if the amount increases significantly or changes in character. Be sure to empty the drains frequently. Record the output, if instructed to do so. The patient may shower; wash the area gently with warm, soapy water. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge in water. Make sure to keep the drain attached securely to the patient's body to prevent pulling or dislocation. Please call the doctor or nurse practitioner if the patient experiences the following: New chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. Vomiting and cannot keep down fluids or medications. Dehydration due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. Blood or dark/black material in vomit or bowel movement. Burning on urination, blood in urine, or discharge. Shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in symptoms, or any new symptoms that concern you. Followup Instructions: Please call Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] office as needed at [Telephone/Fax (1) 2998] as needed. Appointment:- Department: SURGICAL SPECIALTIES When: FRIDAY [2146-9-9] at 10:45 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3000], MD [Telephone/Fax (1) 274] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2146-8-18] Name: [Known lastname 5713],[Known firstname ] Unit No: [Numeric Identifier 5714] Admission Date: [2146-8-7] Discharge Date: [2146-8-20] Date of Birth: [2066-7-17] Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 3149] Addendum: Additional note was made of the following, in Mr. [Known lastname ]' discharge paperwork: "Please note that the patient had a Flexiseal in the recent past, and due to this, he occasionally has small amounts of dark red mucousy discharge mixed with his stool. An anoscopy was performed in the hospital on [8-20], at which time it was determined that he has a small left lateral distal rectal tear, due to the previous Flexiseal. This will heal with time, on its own. Please call the doctor if you see BRIGHT red blood in increased volumes." Discharge Disposition: Extended Care Facility: [Hospital3 2215] - [Location (un) 42] [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2000] MD [MD Number(2) 3151] Completed by:[2146-8-20]	[ "737.30", "V45.79", "518.81", "V10.46", "401.9", "V44.4", "V13.01", "V45.77", "486", "332.0", "584.9", "288.60", "412", "995.92", "863.45", "790.29", "707.22", "038.9", "285.29", "E879.8", "707.03", "276.4" ]	icd9cm	[ [ [] ] ]	[ "49.21", "96.71", "96.04", "99.15" ]	icd9pcs	[ [ [] ] ]	16617, 16846	6935, 10559	311, 342	12793, 12793	2695, 5483	15170, 16594	1412, 1430		11060, 12073		12188, 12772		10585, 11037				12973, 15147					6517, 6912						1149, 1279		1445, 2307							2323, 2676	5519, 6500																		251, 273							370, 1048											12808, 12949						1092, 1126	1295, 1396
65,401	144,201	50516	Discharge summary	report	Admission Date: [2167-10-7] Discharge Date: [2167-10-16] Date of Birth: [2105-6-17] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2006] Chief Complaint: Shortness of breath, intermittent hypoxia. . Reason for MICU transfer: Shortness of breath, PE, tracheostomy, likely bronchoscopy. Major Surgical or Invasive Procedure: Flexible Bronchoscopy Tracheostomy tube changeout History of Present Illness: 62yoF with complicated medical history including DVT, CAD s/p stent, spinal surgery complicated by [First Name3 (LF) 39850], tracheostomy presenting for shortness of breath and transient hypoxia. . The patient has reportedly been undergoing chest PT by her family at home for chronic secretions in the setting of her tracheostomy. She reports having increased secretions recently but denies cough, fevers at home prior to presentation, recent chest pain or shortness of breath prior to her current acute symptoms. The day of presentation, the patient reported shortness of breath at rest and on exertion. She was noted to be hypoxic by her VNA, and was brought to the ED for further evaluation. . Of note, the patient has a history of an upper extremity DVT and was on Coumadin up until a few days ago (last [Doctor First Name ]). She was also recently treated with Bactrim for a UTI. . In the ED, intial VS: 88 99/59 16 88% 3L Her hypoxia on initial presentation subsequently recovered and she was consistently in the low 90's on 3L NC through her tracheostomy throughout the remainder of her ED course. She underwent CTA chest given her symptoms, hypoxia, and history of DVT, which showed a R sided PE with LLL collapse. She was started on a Heparin gtt. CTA chest also showed LLL collapse with debris slightly worse than previously seen. The patient was started on Vanc 1gm x1/Cefepime to cover for HAP/HCAP. Her UA was positive in the setting of multiple UTI's in the past, and she was started on Ceftriaxone 1gm. Tmax in the ED was 101.8 per report but documented as 100.2 in the ED records. Her K was 5.7 without acute EKG changes and she was given Kayexalate 30mg po x1. She was noted to have diarrhea x2 through the course of her ED stay. She was also noted to be hyponatremic and received 1L NS. She was given Morphine 4mg IV x1 for chronic shoulder pain. . On transfer, VS were: 81, 18, 116/62, 97% on 3L On arrival to the ICU, the patient reported continued dyspnea but PO2 was stable on 3L NC through tracheostomy. The patient . . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. . Past Medical History: C5 [First Name7 (NamePattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) 39850] Chronic respiratory failure with trach s/p C6 corpectomy and ACDF C7T1 c allograft and plate c/b CSF leak Stage II pressure ulcers MRSA/Hflu Ventilator-associated Pneumonia Left upper extremity Deep vein thrombosis (DVT) Neurogenic bowel Neurogenic bladder h/o Hypertension (HTN) h/o Myocardia Infarction in 03 s/p BMS to LCcx Diabetes Mellitus (diet controlled) hypercholesterolemia s/p TAH-BSO [2146] hypotension, on florinef/MICU and glycopyrrelate Social History: Occupation: Drugs: Tobacco: prior (30-40 years) 1+ pack/day smoker Alcohol: Other: used to work as [Hospital1 112] clerk . Family History: Hypertension Physical Exam: Admission Physical Exam: Vitals: T: BP: 116/62 P: 81 R: 18 O2: 97% on 3L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: 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: Vitals- 99.2 132/62 70 18 100%RA General: Quadripelegic woman in NAD, lying in bed HEENT: PERRLA, EOMI, Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Limited exam. Coarse breath sounds. CV: RRR, S1 and S2, no m/r/g Abdomen: soft, NT/ND, BSx4 GU: Supra-pubic catheter Ext: Multiple contractures, no edema Neuro: Awake and alert, quadripelegic, CN II-XII intact Pertinent Results: On Admission: [2167-10-6] 08:55PM BLOOD WBC-9.8# RBC-4.53# Hgb-12.1# Hct-37.3# MCV-82# MCH-26.6# MCHC-32.3 RDW-17.9 Plt Ct-286 [2167-10-6] 08:35PM BLOOD PT-12.0 PTT-24.4 INR(PT)-1.0 [2167-10-6] 08:55PM BLOOD Glucose-112* UreaN-33* Creat-0.5 Na-128* K-5.7* Cl-96 HCO3-21* AnGap-17 On Discharge: [2167-10-16] 08:00AM BLOOD WBC-8.0 RBC-4.04* Hgb-11.1* Hct-33.3* MCV-82 MCH-27.5 MCHC-33.3 RDW-17.6* Plt Ct-196 [2167-10-16] 08:00AM BLOOD PT-20.7* PTT-34.3 INR(PT)-1.9* [2167-10-16] 08:00AM BLOOD Glucose-112* UreaN-20 Creat-0.3* Na-139 K-4.1 Cl-102 HCO3-29 AnGap-12 Imaging: CTA ([10-6]): 1. Acute pulmonary embolism involving the distal right main and segmental branches supplying the right lower and middle lobes. No evidence for heart strain. 2. Copious secretions within the left main stem bronchus and left lower lobe bronchus with progression of left lower lobe collapse since the prior study. No pleural fluid. . CXR ([10-6]): IMPRESSION: Limited study with retrocardiac opacity suggesting segmental collapse of the left lower lobe. . EKG: NSR, left axis, TWI diffusely throughout precordial leads, sub-mm STE in V2, V3, Q waves in ?II, III. Brief Hospital Course: Ms. [Known lastname 105209] is a 62 year-old woman with [Known lastname 39850] (complication of past surgery), DVT, CAD s/p stent, and tracheostomy who presented [2167-10-7] with shortness of breath and transient hypoxia. She was found to have right main pulmonary embolism and left lower lobe collapse. #. Pulmonary Embolism: The patient developed acutely worsening SOB and presented to the ED here. On arrival a CTA was done which revealed a pulmonary embolism in the right pulmonary artery. The patient had been taking coumadin until 6 days PTA for an UE DVT. She had a subtherapeutic INR on admission. Heparin drip was started but she was then switched to enoxaparin as a bridge to coumadin therapy, which was started at 5 mg dose on [2167-10-8]. [Of note: enoxaparin has a black box warning from the FDA for patients who have received procedures of the spinal column. This patient's spinal surgery is remote and no other procedures are planned at this time. The enoxaparin is only a bridge to coumadin and should be discontinued upon therapeutic INR]. In house the patient's INRs increased appropriatly and IS 1.9 on day of discharge with goal of [3-12]. The patient will follow with the [Hospital 191] [Hospital 2786] clinic. She is being discharged on 5mg of warfarin daily. . #. LLL Collapse: In addition to the PE described above, initial imaging also revealed left lower lung lobe collapse with debris. LLL collapse was believed to be [3-11] mucus plugging given significant yellowish-white sputum suctioned on initial deep tracheostomy suction in the ED. Patient was given one dose of vanc/cefepime in the ED for suspected PNA, but this treatment was discontinued on the floor. Therapeutic bronchoscopy was performed on the floor confirming mucus plugging and the LLL was transiently re-expanded however it collapsed again. Also tried positive pressure ventilation which too transiently expanded the lung. The patient was continued with intermittent deep-suctioning and cough-assist throughout her hospital stay. At time of discharge, the LLL is still collapsed although the patient is reporting less secretions and denies any subjective respiratory compromise. Will go home with valve in place and home oxygen. . # UTI (Pansensitive Pseudomonas): Patient has history of recurrent UTI's, even following suprapubic catheter placement. Here, positive UA and low grade documented fever 100.2 in the ED. Started on ciprofloxacin (IV initially and then transitioned to PO). Started on a 7 day course on [2167-10-7]. Suprapubic catheter replaced on [2167-10-10]. The patient completed her course and remained afebrile during her hospital stay. . #. [Year (4 digits) ]: Spinal surgery c/b [Year (4 digits) 39850] in [2167] as above. Multiple contractures and pain. The patient was continued on her home pain regimen with the exception of NSAIDs given interaction with lovenox. Did have [2-8] nights with burning pain on left lateral leg although this resolved without itnervention. . #. HTN: Continued on home Lisinopril. . #. Anxiety: Continued on lorazepam as needed and zolpidem for sleep. . #. GERD: Continued on PPI. . #. HL: Continued on simvastatin and ASA. Medications on Admission: aspirin 81 mg Tablet, Chewable [Month/Day (2) ]: One (1) Tablet, Chewable PO DAILY (Daily). tizanidine 2 mg Tablet [Month/Day (2) ]: Three (3) Tablet PO BID (2 times a day). diazepam 2 mg Tablet [Month/Day (2) ]: 0.5 Tablet PO Q8H (every 8 hours) as needed for anxiety. docusate sodium 50 mg/5 mL Liquid [Month/Day (2) ]: One (1) PO BID (2 times a day). bisacodyl 10 mg Suppository [Month/Day (2) ]: One (1) Rectal once a day. magnesium hydroxide 400 mg/5 mL Suspension [Month/Day (2) ]: Thirty (30) ml PO once a day as needed for constipation. lisinopril 5 mg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). simvastatin 10 mg Tablet [Month/Day (2) ]: Two (2) Tablet PO DAILY (Daily). lansoprazole 15 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] once a day. gabapentin 250 mg/5 mL Solution [Last Name (STitle) ]: Eight Hundred (800) mg PO twice a day. gabapentin 250 mg/5 mL Solution [Last Name (STitle) ]: Four Hundred (400) mg PO 1200 Daily. acetaminophen 650 mg/20.3 mL Solution [Last Name (STitle) ]: Six [Age over 90 1230]y (650) mg PO every six (6) hours. Combivent 18-103 mcg/Actuation Aerosol [Age over 90 ]: One (1) Inhalation every six (6) hours. baclofen 10 mg Tablet [Age over 90 ]: Two (2) Tablet PO BID (2 times a day). baclofen 10 mg Tablet [Age over 90 ]: Three (3) Tablet PO DAILY (Daily). capsaicin 0.075 % Cream [Age over 90 ]: One (1) Topical every six (6) hours. Naproxen as needed for pain Discharge Medications: 1. Lovenox 80 mg/0.8 mL Syringe [Age over 90 ]: Seventy (70) mg Subcutaneous twice a day for 4 days: Please administer 70mg (waste first 0.1mL) . Disp:8 Syringes Refills:0 2. aspirin 81 mg Tablet, Chewable [Age over 90 ]: One (1) Tablet, Chewable PO DAILY (Daily). 3. tizanidine 2 mg Tablet [Age over 90 ]: Three (3) Tablet PO BID (2 times a day). 4. diazepam 2 mg Tablet [Age over 90 ]: 0.5 Tablet PO Q8H (every 8 hours) as needed for anxiety. 5. docusate sodium 50 mg/5 mL Liquid [Age over 90 ]: One (1) PO BID (2 times a day). 6. bisacodyl 10 mg Suppository [Age over 90 ]: One (1) Rectal once a day. 7. magnesium hydroxide 400 mg/5 mL Suspension [Age over 90 ]: Thirty (30) ml PO once a day as needed for constipation. 8. lisinopril 5 mg Tablet [Age over 90 ]: One (1) Tablet PO DAILY (Daily). 9. simvastatin 10 mg Tablet [Age over 90 ]: Two (2) Tablet PO DAILY (Daily). 10. Home Oxygen Oxygen 40% by air compressor via trach. Diagnosis: Left Lower Lobe lung collapse. 11. lansoprazole 15 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] once a day. 12. gabapentin 250 mg/5 mL Solution [Last Name (STitle) ]: Eight Hundred (800) mg PO twice a day. 13. gabapentin 250 mg/5 mL Solution [Last Name (STitle) ]: Four Hundred (400) mg PO 1200 Daily. 14. acetaminophen 650 mg/20.3 mL Solution [Last Name (STitle) ]: Six [Age over 90 1230]y (650) mg PO every six (6) hours. 15. Combivent 18-103 mcg/Actuation Aerosol [Age over 90 ]: One (1) Inhalation every six (6) hours. 16. baclofen 10 mg Tablet [Age over 90 ]: Two (2) Tablet PO BID (2 times a day). 17. baclofen 10 mg Tablet [Age over 90 ]: Three (3) Tablet PO DAILY (Daily). 18. capsaicin 0.075 % Cream [Age over 90 ]: One (1) Topical every six (6) hours. 19. Ultram 50 mg Tablet [Age over 90 ]: One (1) Tablet PO every six (6) hours as needed for pain. Disp:30 Tablet(s) Refills:0 20. warfarin 2.5 mg Tablet [Age over 90 ]: Two (2) Tablet PO once a day. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Pulmonary Embolism Urinary Tract Infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: [Name (NI) 56633] Discharge Instructions: It was a pleasure taking care of you at [Hospital1 18]! You were admitted due to difficulty with breathing and were found to have a pulmonary embolism (clot in the lung) and a partial left lung collapse. During your stay you were started on anti-coagulation for the lung clot and were provided with agressive respiratory therapy including deep suctioning and cough-assist. You are now ready to return home with VNA services. Please note the following changes to your medication regimen: 1) START Warfarin 5mg daily and follow-up with the [Hospital 191] [Hospital 2786] clinic for changes in dosing. 2) CONTINUE Lovenox injections for 2 more days or until INR >2.0 3) STOP Naproxen while using the Lovenox injections 4) START home oxygen as needed for shortness of breath or hypoxia Please see below for follow-up instructions: Followup Instructions: Please follow up with the [Hospital 2786] clinic at [Hospital ] as instructed. Additionally, you have a primary care appointment with Dr. [First Name (STitle) 3535] as below: Department: [Hospital3 249] When: THURSDAY [2167-10-22] at 1 PM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2167-10-18]	[ "E912", "E878.8", "787.91", "518.0", "276.7", "933.1", "041.6", "V15.82", "458.9", "250.00", "V49.86", "V12.51", "719.41", "V44.0", "707.05", "599.0", "907.2", "344.00", "707.22", "415.19", "518.83", "300.00", "412", "564.81", "338.29", "596.54", "276.1" ]	icd9cm	[ [ [] ] ]	[ "96.6", "97.23", "96.71", "33.24", "59.94" ]	icd9pcs	[ [ [] ] ]	12996, 13067	6020, 9268	437, 489	13154, 13154	4813, 4813	14168, 14691	3799, 3813		10876, 12973		13088, 13133		9294, 10853				13300, 14120													3853, 4367																	5122, 5997				2604, 3054					266, 399							517, 2585									4827, 5108		13169, 13276		14145, 14145				3076, 3638	3654, 3783						4392, 4794
61,676	131,613	18479	Discharge summary	report	Admission Date: [2164-7-2] Discharge Date: [2164-7-11] Date of Birth: [2117-1-6] Sex: M Service: SURGERY Allergies: Feldene / Naproxen Attending:[First Name3 (LF) 2777] Chief Complaint: right rest pain and ischemia Major Surgical or Invasive Procedure: [2164-7-4] OPERATIONS: 1. Evacuation of right lower extremity hematoma. 2. Right upper extremity cephalic vein harvest. 3. Exploration of right lower extremity vein graft with vein patch angioplasty. [2164-7-3] OPERATIONS: 1. Ultrasound-guided puncture of the left common femoral artery. 2. Contralateral third-order catheterization of the right superficial femoral artery. 3. Abdominal aortogram. 4. Serial arteriogram of the right lower extremity. 5. AngioJet thrombectomy of the right superficial femoral artery with embolic protection. Stenting of the right superficial femoral artery. 6. Perclose closure of left common femoral arteriotomy History of Present Illness: This is a 47-year-old male with a history of severe upper and lower extremity peripheral vascular disease. He had previous bilateral lower extremity revascularizations for popliteal aneurysms. Several weeks ago his right bypass graft thrombosed resulting in ischemia and rest pain. He presents for re-do bypass using arm vein. Past Medical History: B/L popliteal aneurysms, s/p left SFA to AT bypass graft '[51] & revision '[58], Multiple venous and arterial clotting events with no known etiology, GERD, hiatal hernia, polyarteritis nodosa, hypercoagulopathy workup negative to date, chronic LUE pain with a presumptive dx of vasculitis with Raynaud's phenomena (pt was formerly on nifedipine xl 30') Social History: Smoking 1 PPD ETOH: three, 6 packs daily Family History: NC Physical Exam: VVS Bp 90-100/60's, HR 50-60's, afebrile General: A&OX3, NAD CV: RRR Pulm: CTAB ant Abd: soft, NT/ND; no groin hematoma Ext: LLE dop PT/DP; palpable graft at knee and R DP Pertinent Results: [2164-7-11] 03:34AM BLOOD WBC-8.2 RBC-2.95* Hgb-9.6* Hct-27.7* MCV-94 MCH-32.7* MCHC-34.8 RDW-13.5 Plt Ct-452* [2164-7-10] 01:47AM BLOOD Hct-28.7* [2164-7-11] 03:34AM BLOOD Plt Ct-452* [2164-7-11] 03:34AM BLOOD PT-16.5* PTT-44.7* INR(PT)-1.5* [2164-7-11] 03:34AM BLOOD Glucose-104* UreaN-9 Creat-0.9 Na-141 K-3.7 Cl-106 HCO3-26 AnGap-13 [2164-7-4] 11:26AM BLOOD ALT-10 AST-33 LD(LDH)-331* TotBili-0.5 [2164-7-11] 03:34AM BLOOD Calcium-8.5 Phos-4.5 Mg-1.9 Brief Hospital Course: [2164-7-2] Underwent Re-do superficial femoral artery to anterior tibial artery bypass graft with nonreversed right basilic vein for right bypass graft thrombosis resulting in ischemia and rest pain. No complications. Extubated and transfered to PACU then [Wardname ]. VSS. Pulses intact. On Hepain gtt. During OR procedure- discovered a large amount of thrombus within the superficial femoral artery intraoperatively. Decided to return to the endo [**] for diagnostic angiogram. [2164-7-3] Overnight, no events. Underwent AngioJet thrombectomy of the right superficial femoral artery with embolic protection. Stenting of the right superficial femoral artery. Perclose closure of left common femoral arteriotomy. Procedure without complication and he was transfered to the floor in stable condition. However, almost immediately upon arrival to floor-the patient abruptly became agitated at 1pm, trying to remove his foley, his A-line, and his central line. He refused to lie flat and sat up in his bed, threatening to leave AMA. Due to a concern for his graft and groin, a number of nurses and physicians were called to the patient's room to restrain him. He received 2mg of ativan but became even more agitated, and a code purple was called. He was then put in 4 point leather restraints due to a concern for harm to himself. He was ultimately given 3mg of ativan and 7.5mg of haldol with good effect. At that time, the restraints were switched to soft cuffs. The patient's vital signs remained stable over this time with the exception of some tachycardia. The graft and his DP pulse remained palpable, though the calf became edematous. His foot was warm. There was no groin hematoma. His arm dressing showed some strike-though, but the wound was intact when the dressing was taken down. His foley had been mildly bloody prior to this episode, and he continued to have hematura. The foley was kept in place. Post operative Assessment: 47M POD0 s/p proximal right SFA angioplasty and stent with acute agitation, likely the result of EtOH withdrawal, otherwise stable. CIWA scale was substantially increased to cover withdrawal symptoms per psych nurses. Transfered to CVICU for monitoring. [2164-7-4]. Remained in CVICU overnight under heavy sedation for DT/ETOH withdrawl. Hematoma larger, underwent Evacuation of right lower extremity hematoma, Right upper extremity cephalic vein harvest, Exploration of right lower extremity vein graft with vein patch angioplasty. Remained intubated/sedated for ETOH withdrawl. Transfused. SBP maintained 100-140. [2164-7-5] Overnight, in CVICU. Intubated. Clonidine patch, Valium started. Febrile to 102.6- pan cultured, Vanco and Cefepime started. [Date range (1) 50819] Extubated. Continue withdrawl/CIWA and dilaudid for pain. Remained to CVICU for close montioring, withdrawl. Pulses stable. [Date range (1) 50820] VSS. No events. Transfered to VICU/[Wardname ] for continued care. Working with PT. Psychiatry consulted, following. On Heparing gtt. Coumadin restarted. Sputum + for MSSA, HFlu. STarted Nafacillin. [7-11]-VSS. No events. PT cleared pt for home with home PT and rolling walker. Will discharge on Dicloxacillin, Lovenox and Coumadin. Lovenox teaching performed, pt able to administer. Resume anticoagulation management by PCP. [Name10 (NameIs) ] up office visit arranged with PCP and discharge summary faxed to his office. Post op with Dr. [Last Name (STitle) ] scheduled. Medications on Admission: Cilostazol 100 mg PO BID prn claudication pain, coumadin, Citalopram 20 mg PO DAILY, Cyclobenzaprine 10 mg prn muscle spasm, Lansoprazole 30 mg Tablet DR [Last Name (STitle) ] DAILY, Psyllium 1 Packet PO DAILY, Thiamine HCl 100 mg PO DAILY, Folic Acid 1 mg PO DAILY, Metoprolol Tartrate 12.5 mg PO BID, Simvastatin 20 mg PO DAILY, Discharge Medications: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for muscle spasm. 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Last Name (STitle) *]:30 Tablet(s)* Refills:0 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): 12.5mg twice per day Refills from PCP [Last Name (LF) ],[First Name3 (LF) 5684] [Name Initial (PRE) ] [Telephone/Fax (1) 50772]. [Telephone/Fax (1) ]:30 Tablet(s) Refills:0 8. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q 12H (Every 12 Hours): Continue until INR is >2 and as directed by PCP. [Name Initial (NameIs) ]:10 1 Refills:0 9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Refills per PCP [Last Name (LF) ],[First Name3 (LF) 5684] [Name Initial (PRE) ] Phone: [Telephone/Fax (1) 50772] . [Telephone/Fax (1) ]:30 Tablet(s) Refills:0 10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Refills by PCP [Last Name (LF) ],[First Name3 (LF) 5684] [Name Initial (PRE) ] Phone: [Telephone/Fax (1) 50772] . [Telephone/Fax (1) ]:30 Tablet(s) Refills:0 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): while on Plavix, then may resume home med- prevacid. [Telephone/Fax (1) ]:30 Tablet(s) Refills:0 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Refill per PCP [Last Name (LF) ],[First Name3 (LF) 5684] [Name Initial (PRE) ] . [Name Initial (PRE) ]:30 Tablet(s) Refills:0 13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [4-17] hours as needed for pain. [Month/Day (3) ]:50 Tablet(s) Refills:0 14. Outpatient Lab Work INR 2x per week and prn as directed by PCP [Last Name (LF) ],[First Name3 (LF) 5684] [Name Initial (PRE) ] Phone: [Telephone/Fax (1) 50772] Fax [Telephone/Fax (1) 50773] Results to Dr. [First Name (STitle) ] 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 16. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days. [First Name (STitle) ]:28 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: ALL CARE VNA & HOSPICE Discharge Diagnosis: 47M s/p third redo R SFA-AT BPG with R basilic vein [7-2], and s/p Proximal SFA angioplasty and stent [7-3], s/p washout and patch angioplasty with R cephalic vein [7-4] PMH: B/L popliteal aneurysms, multiple venous and arterial clotting events with no known etiology, GERD, hiatal hernia, polyarteritis nodosa, hypercoagulopathy workup negative to date, chronic LUE pain with a presumptive dx of vasculitis with Raynaud's phenomena (pt was formerly on nifedipine xl 30') PSH: left SFA to AT bypass graft '[51] & revision '[58] Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). (Rolling walker and continued home PT) Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Angioplasty/Stent Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? If instructed, take Plavix (Clopidogrel) 75mg once daily X 1 month only ?????? 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 [2-15] 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 [3-15] weeks for post procedure check and ultrasound 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) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office [Telephone/Fax (1) 1237]. If bleeding does not stop, call 911 for transfer to closest Emergency Room. 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 ?????? Unless you were told not to bear any weight on operative foot: 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 swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [2-15] 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 ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase 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 (unless you have stitches or foot incisions) no direct spray on incision, 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 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD Phone:[Telephone/Fax (1) 2625] Date/Time:[2164-7-19] 10:30 You have a visit scheduled with your PCP [Last Name (NamePattern4) ] [7-24] at 1215pm [Last Name (LF) ],[First Name3 (LF) 5684] E Phone: [Telephone/Fax (1) 50772] Continue Lovenox/Coumadin and INR/lab draws as directed by his office Completed by:[2164-7-11]	[ "446.0", "289.81", "996.74", "291.0", "530.81", "444.22", "486", "305.1", "303.91", "E878.2", "443.0", "285.9" ]	icd9cm	[ [ [] ] ]	[ "39.49", "86.09", "39.50", "39.56", "88.48", "00.45", "39.79", "00.40", "88.42", "39.90", "99.04" ]	icd9pcs	[ [ [] ] ]	8896, 8949	2519, 6011	305, 981	9543, 9543	2012, 2496	15163, 15602	1799, 1803		6396, 8873		8970, 9522		6037, 6373				9765, 11770	14756, 15140												1819, 1993																										237, 267							1009, 1338											9558, 9741						1360, 1723	1739, 1783
20,874	183,653	26147	Discharge summary	report	Admission Date: [2170-1-31] Discharge Date: [2170-2-9] Date of Birth: [2091-9-29] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1267] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2170-2-1] Urgent Three Vessel Coronary Artery Bypass Grafting(LIMA to LAD, vein graft to ramus, vein graft to PDA) [2170-2-1] Placement of IABP History of Present Illness: Mr. [Known lastname ] is a 78 year old male who previously did not see a physician in over 20 years, took no medications and was generally feeling well. He presented to [Hospital3 45967] 3 days prior to this admission with shortness of breath. He [Hospital3 1834] extensive evaluation. An echocardiogram revealed an LVEF of 15-20%. Subsequent cardiac catheterization showed severe three vessel coronary artery disease. During his hospitalization, he went on to develop chest pain which improved with intravenous Nitroglycerin. He was concomitantly diagnosed with diabetes mellitus with a HgbA1c greater than 10. He was urgently transferred to the [Hospital1 18] for cardiac surgical intervention. Past Medical History: Coronary Artery Disease, Congestive Heart Failure, Diabetes Mellitus, Peripheral Vascular Disease, Thrombocytopenia, Peptic Ulcer Disease, s/p partial gastrectomy, s/p hernia repair Social History: Admits to 80-90 pack year history of tobacco, quit 10 years ago. He denies history of excessive ETOH. He was widowed 6 months ago. He is retired from [Company ]. Family History: Sister with diabetes. No known family history of premature CAD. Physical Exam: Vitals: BP 160/80, HR 74, RR 14, SAT 96% on 2L General: elderly male in no acute distress HEENT: oropharynx benign, poor dental health Neck: supple, no JVD, Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: alert and oriented, cranial nerves grossly intact, no focal motor deficits noted. Pertinent Results: [2170-2-1] 01:19AM BLOOD WBC-6.8 RBC-3.97* Hgb-11.4* Hct-33.4* MCV-84 MCH-28.8 MCHC-34.2 RDW-13.6 Plt Ct-137* [2170-2-1] 01:19AM BLOOD PT-13.6* PTT-42.1* INR(PT)-1.2 [2170-2-1] 01:19AM BLOOD Glucose-213* UreaN-24* Creat-1.3* Na-138 K-3.5 Cl-102 HCO3-31 AnGap-9 [2170-2-1] 10:43AM BLOOD CK-MB-NotDone cTropnT-0.03* [2170-2-1] 01:19AM BLOOD %HbA1c-11.2* [Hgb]-DONE [A1c]-DONE [2170-2-6] 07:25AM BLOOD WBC-10.7 RBC-3.66* Hgb-10.5* Hct-31.4* MCV-86 MCH-28.7 MCHC-33.4 RDW-15.0 Plt Ct-160 [2170-2-9] 06:45AM BLOOD Hct-28.5* [2170-2-6] 07:25AM BLOOD Plt Ct-160 [2170-2-9] 06:45AM BLOOD Glucose-207* UreaN-40* Creat-2.1* Na-136 K-4.3 Cl-100 HCO3-25 AnGap-15 [2170-2-9] 06:45AM BLOOD Calcium-7.7* Phos-3.0# Mg-2.3 [2170-2-1] 01:19AM BLOOD %HbA1c-11.2* [Hgb]-DONE [A1c]-DONE Brief Hospital Course: Shortly after arrival, Mr. [Known lastname ] developed recurrent, persistent chest pain despite intravenous therapy. For refractory ischemia, Mr. [Known lastname ] [Last Name (Titles) 1834] placement of an IABP. He was then urgently brought to the operating room for coronary artery bypass grafting. The operation was uneventful. Following the operation, he was brought to the CSRU for invasive monitoring. There he was extubated and weaned from inotropic support. The IABP was removed on postoperative day one without complication. He was transfused with PRBCs and platelet to maintain normal levels. He did well and transferred to the SDU on postoperative day two. Intermittent episodes of atrial fibrillation were noted and treated with Amiodarone. He maintained stable hemodynamics and remained mostly in a normal sinus rhythm/sinus bradycardia with rates between 69 and 48 beats per minute. The [Last Name (un) ] center was consulted to assist in the management of his newly diagnosed diabetes mellitus. Insulin therapy was initiated. Over several days, medical therapy was optimized and he continued to make clinical improvements. Once his blood sugars were more well controlled, he was cleared for discharge to rehab on POD #8. His amiodarone is to be tapered down on [2-13], and [Last Name (un) ] recommends Humalog 75/25 22 units every AM, and 14 units with dinner. T 98.0 SR 70 with occ. PVCs, 120/50 RR 18 sat 97% RA Medications on Admission: Patient took no medications at home preoperatively 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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for 1 months. 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day. 8. Humalog 75/25: 22units qAM, 14 units at dinner Discharge Disposition: Extended Care Facility: [Location (un) ] [Doctor Last Name ] Discharge Diagnosis: Coronary Artery Disease, Congestive Heart Failure, Diabetes Mellitus, Peripheral Vascular Disease, Thrombocytopenia, Peptic Ulcer Disease, s/p partial gastrectomy, s/p hernia repair, Postoperative Atrial Fibrillation Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Cardiac surgeon, Dr. [Last Name (STitle) ] in [5-16] weeks. Local PCP [Last Name (NamePattern4) ] [3-16] weeks. Local cardiologist Dr. [First Name8 (NamePattern2) 122] [Last Name (NamePattern1) 64868] in [3-16] weeks. [Last Name (un) ] Center, Dr.[First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in [4-14] weeks Completed by:[2170-2-9]	[ "427.31", "997.1", "410.81", "443.9", "428.0", "414.01", "287.5" ]	icd9cm	[ [ [] ] ]	[ "39.61", "36.15", "36.12", "97.44", "37.61", "99.04" ]	icd9pcs	[ [ [] ] ]	5226, 5297	2996, 4457	331, 485	5558, 5565	2162, 2973	5884, 6280	1631, 1696		4558, 5203		5318, 5537		4483, 4535				5589, 5861													1711, 2143																										281, 293							513, 1227																	1249, 1432	1448, 1615
44,437	181,557	49055	Discharge summary	report	Admission Date: [2195-11-25] Discharge Date: [2195-12-10] Date of Birth: [2143-12-28] Sex: F Service: MEDICINE Allergies: Penicillins / Shellfish Derived Attending:[First Name3 (LF) 1945] Chief Complaint: Left complex parapneumonic effusion. Major Surgical or Invasive Procedure: 1. Left video-assisted thoracoscopy total pulmonary decortication. 2. Chest tube placement and removal 3. Pericardiocentesis History of Present Illness: This is a 51 year old female with history of pulmonary sarcoidosis, Sjogren's, and rheumatoid arthritis, recently admitted from [11-20] - [11-24] with Salmonella bacteria. She was sent home with ciprofloxacin 500mg PO BID for a total of two weeks therapy. According to patient, she went home from the hospital feeling better but upon returning home, she started again to feel shortness of breath. At night in bed she had worsening left sided chest pain underneath her left breast which was sharp and persistent for 12 hours. She denied associated nausea/diaphoresis. In the morning the shortness of breath and chest pain worsened and she presented to the hospital for these complaints. Also had a fever to 101 at home. In the ED she was febrile to 102 and appeared uncomfortable; she had decreased air movement in the left lower lobe and a new leukocytosis to 13.8. Currently she is on Aztreonam (given Penicillin allergy)Cipro and vancomycin. She was also noted to have a new [Last Name (un) ], but without hyperbilirubinemia. A pig tail catheter was placed in the left pleural space by IR and 1 L of yellow coloured serous fluid was drained. Past Medical History: -Sarcoidosis - Patient states presented with butterfly rash and rashes on her shins. Non-painful, no palpable mass. Dx in [2191]; hilar adenopathy with non caseating granulomas on mediastinoscopy biopsy. Butterfly rash and body rashes have been responsive to plaquenil. Also has arthalgias, fatigue, weakness. -Sjogrens Disease - Dry eyes, dry mouth, dry nose; needs to wear glasses now; Markers from [10/2195]: [Doctor First Name ] - 1:640, Anti-Sm - Neg, Anti-dsDNA - neg, Anti-Ro - 215 (high), Anti-La - 94 (high), Anti-RNP - neg -Positive Anti-Smooth Muscle Antibody, 1:20 titer -MI - [2177] -Cardiac Arrhythmia -Asthma -Allergic Rhinitis -Morbid Obesity -MGUS - [2191] -Stage 2 Chronic Kidney Disease - w/out proteinura and benign sediment; rheum visit on [2195-9-16] rec'd against biopsy. -Chest Pain - Several episodes of [2191-7-16]. Admitted for atypical chest pain. (left arm pain and vague CP. H/o pedal edema.) EF in [2191] 69%. W/u included evidence of anterior septal MI. -Chronic Anemia - since [2178] -Hypomenorrhea/oligomenorrhea - [2178] -Menometrorrhagia - [2189] . Surgical History: splenectomy [2162] Cholecystectomy [2162] Appendectomy [2162] Gastric Bypass in [2170] Multiple Hernia Repairs C section x 2 Tubal ligation - [2163] Social History: The patient lives alone in [Location (un) 16174]. She is married but does not live with her husband. Three children (two sons, one daughter) live near by. Her daughter [Name (NI) ] is her health care proxy ([Telephone/Fax (1) 102945]). Works as a social worker at homeless shelter. Denies tobacco use, quit EtOH use 5 months ago, and denies other illict drug us. Family History: 7 siblings. Mother: Traumatic [Name (NI) 3495] Attack at age 26; sickle cell trait Sister: Renal Failure s/p transplant Brother: Diabetes Sister: Multiple Myeloma - died in [2181] Sister: sickle cell disease Physical Exam: Upon admission: Vitals: 99, 124/80, 97% 2 L, RR 12 General: Dark-skinned Afro-Carribean female in mild pain, no respiratory distress HEENT: Anicteric, PERRL. Tenderness overlying temporal vessels. No TMJ tenderness. No oropharyngeal erythema or oral ulceration. Neck: no lymphadenopathy Lungs: no appreciable difference in lung sounds on either side; poor inspiratory effort overall, but no noted rales or egophony CV: mild systolic ejection murmur radiating to carotids Abdomen: soft and nontender, obese abdomen Ext: no edema noted; no rashes or effusions evident; no synovitis appreciable Neuro: alert and oriented X 3, drowsy, nonfocal exam Skin: No rashes evident At discharge: Vitals: T:97.7 Tmax:98.7 BP:138/97 HR:101 (90-150) RR:20 O2:98% on RA Pulsus: systolic 124-->120. General: Morbidly obese woman with abnormal fat distribution (very large upper arms, normal appearing lower arms). Alert, oriented, no acute distress. HEENT: Sclera anicteric, PERRL, MMM without lesions Neck: supple, JVP not visible, no LAD Lungs: CTAB, no w/r/c. Chest tube site is clean dry and intact. CV: RRR, normal S1 + S2, no murmurs, rubs, gallops appreciated. Abdomen: Obese, +BS, soft, non-tender, nondistended. Ext: bilateral 2+ ankle edema, improved from yesterday; no spinal or paraspinal tenderness; warm, well perfused, DPs not palpable bilaterally; no clubbing or cyanosis Neuro: CNII-XII intact. Pertinent Results: Upon admission: [2195-11-25] 12:30PM BLOOD WBC-13.8# RBC-4.47 Hgb-12.4# Hct-38.8# MCV-87 MCH-27.6 MCHC-31.9 RDW-15.4 Plt Ct-399 [2195-11-26] 04:30AM BLOOD WBC-19.1 RBC-3.90* Hgb-10.9* Hct-33.0* MCV-85 MCH-28.0 MCHC-33.1 RDW-15.6* Plt Ct-390 [2195-11-25] 12:30PM BLOOD Neuts-89.2* Lymphs-7.1* Monos-2.2 Eos-1.0 Baso-0.6 [2195-11-27] 04:35AM BLOOD Hgb A-100 Hgb S-0 Hgb C-0 [2195-11-25] 12:30PM BLOOD PT-14.5* PTT-23.3 INR(PT)-1.3* [2195-11-26] 04:30AM BLOOD ESR-99* [2195-11-26] 05:15PM BLOOD Sickle-NEG [2195-11-25] 12:30PM BLOOD Glucose-76 UreaN-17 Creat-1.4* Na-138 K-4.0 Cl-103 HCO3-19* AnGap-20 [2195-11-26] 04:30AM BLOOD ALT-143* AST-140* LD(LDH)-244 CK(CPK)-30 AlkPhos-313* TotBili-1.1 DirBili-0.7* IndBili-0.4 [2195-11-26] 04:30AM BLOOD Albumin-2.9* Calcium-8.7 Phos-5.9# Mg-1.9 [2195-11-26] 04:30AM BLOOD TSH-6.7 [2195-11-27] 04:35AM BLOOD TSH-12* [2195-11-27] 04:35AM BLOOD T4-4.5* T3-66* [2195-11-26] 04:30AM BLOOD RheuFac-21* CRP-GREATER TH [2195-11-26] 07:47AM BLOOD [Doctor First Name ]-POSITIVE * Titer-1:640 dsDNA-POSITIVE * [2195-11-26] 05:15PM BLOOD C3-104 C4-25 [2195-11-26] 05:15PM BLOOD HIV Ab-NEGATIVE [2195-11-25] 12:38PM BLOOD Glucose-79 Lactate-2.3* Na-139 K-3.7 Cl-100 calHCO3-24 [2195-11-25] 12:38PM BLOOD freeCa-0.98* At discharge: [2195-12-9] 06:50AM BLOOD WBC-13.7* RBC-3.13* Hgb-9.0* Hct-27.5* MCV-88 MCH-28.7 MCHC-32.6 RDW-18.1* Plt Ct-593* [2195-12-9] 06:50AM BLOOD PT-14.4* PTT-22.6 INR(PT)-1.2* [2195-12-6] 08:51AM BLOOD ACA IgG-PND ACA IgM-PND [2195-12-6] 08:51AM BLOOD Lupus-NEG [2195-12-9] 06:50AM BLOOD Glucose-70 UreaN-26* Creat-1.2* Na-141 K-4.7 Cl-107 HCO3-24 AnGap-15 [2195-12-9] 06:50AM BLOOD ALT-39 AST-28 AlkPhos-329* TotBili-0.2 [2195-12-9] 06:50AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.9 [2195-12-6] 08:51AM BLOOD AMA-NEGATIVE [2195-12-6] 08:51AM BLOOD RNP ANTIBODY-Negative [2195-12-6] 08:51AM BLOOD CCP ANTIBODY, IGG-Negative [2195-12-6] 08:51AM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA, IGM, IGG)-PND Micro: [11-30] Pleural tissue: sparse growth of staph aureus Otherwise no growth in blood, urine, and pericardial specimens. Imaging: [2195-11-25] CXR IMPRESSION: Interval significant enlargement of now large left pleural effusion with overlying atelectasis. Underlying consolidation not excluded. Persistent small right pleural effusion. [2195-11-26] RUQ ultrasound: 1. Dilated common bile duct with no stone or obstructing mass identified. Mild central intrahepatic biliary dilatation also seen. An MRCP could be performed for further characterization. 2. Increased echogenicity of the kidneys is suggestive of diffuse renal parenchymal disease. 3. Bilateral pleural effusions. [2195-11-28] MRCP: 1. Mild central intrahepatic and CBD dilatation, similar to prior ultrasound, without evidence of filling defects or extraluminal mass lesion. 2. Status post cholecystectomy. 3. Bilateral moderate pleural effusions and trace ascites. [2195-11-30] Pleural pathology: 1. Left pleural debris (A-B): Neutrophilic aggregates with fibrin exudate suggesting empyema. 2. Pleura, left lower lobe (C): Neutrophilic aggregates, fibrinous exudate, and reactive fibroblastic proliferation, consistent with organizing pleuritis. [2195-12-4] Cardiac Cath with pericardiocentesis: FINAL DIAGNOSIS: 1. Large pericardial effusion with pericardial tamponade. 2. 430cc serous fluid removed. 3. Persistent elevated pericardial pressures and moderate pulmonary hypertension post-intervention. [2195-12-4] Echo: Large effusion and RV collapse consistent with tamponade physiology. Post-pericardiocentesis images demonstrate resolution of RV collapse and significant reduction in effusion size. [2195-12-4] CTA: 1. Compared to [2195-11-20], new large pericardial pleural effusion with [Doctor Last Name ] from 40 to 50 which might be related to hemopericardium or artifact. 2. Compared to [2195-11-20], slightly increased left pleural effusion and new small left pneumothorax with a chest tube in place. Left chest wall subcutaneous emphysema. 3. Unchanged moderate right pleural effusion and basilar atelectasis. [2195-12-5] Echo: The left atrium is mildly dilated. The estimated right atrial pressure is 10-15mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is top normal/borderline dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. with borderline normal free wall function. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. [2195-12-7] Echo: There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a very small circumferential pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There is no echo evidence of tamponade physiology. [2195-12-7] CXR: IMPRESSION: 1. Interval removal of chest tube without new pneumothorax but stable left lateral pleural air fluid collection as well as bilateral left greater than right dependent effusions and atelectasis. 2. Increasing left mid lung consolidation concerning for worsening volume overload or developing pneumonia. [2195-12-8] CXR: Enlargement of the cardiomediastinal sillouhette is stable from prior CT from [12-4]. In the prior CT, there was mediastinal lymphadenopathy and pericardial effusion. Moderate left hydropneumothorax with a small air component is stable. Mild-to-moderate right pleural effusion, has minimally increased. Bibasilar atelectasis, left greater than right have increased. There is mild vascular congestion. Brief Hospital Course: Ms. [Known lastname 102946] was re-admitted to the hosptial for symptoms of worsening shortness of breath, and was found to have a loculated pleural effusion, likely a rheumatoid effusion although parapneumonic could never be completely excluded. She underwent left VATS with decortication. Post-operative course complicated by atrial fibrillation with hypotension, a pericardial effusion, and volume overload. She completed therapy for salmonella bacteremia during her admission. . PLEURAL EFFUSION: Ms. [Name14 (STitle) 102947] was admitted for worsening shortness of breath. CXR revealed worsening bilateral pleural effusions. On HD 2, interventional radiology placed a left pigtail and performed left thoracentesis for 400cc. Thoracic surgery was consulted and recommended left VATs decortication. She was admitted to thoracic surgery following left video-assisted thoracoscopy total pulmonary decortication. Post operative course complicated by rapid atrial fibrillation with hypotension and pericardial effusion both described below. Posterior, apical, and basilar chest tubes were to suction for 24 hrs with small serosanguinous drainage. They were placed to water-seal for 24 hrs with air-leak. The apical tube was removed on [2195-12-3]. The basilar was converted to Pneumostat secondary to Coag neg staph growth on pleural tissue and was removed on [2195-12-7]. She completed a full course of Aztreonam, Vancomycin and Ciprofloxacin. . PERICARDIAL EFFUSION: Post operative course of left VATS decortication complicated by shortness of breath. A CTA which revealed pericardial effusion. The patient had cardiac cath showing cardiac tamponade physiology with RV collapse. A pericardiocentesis drained 450cc of yellow serous fluid. The patient's shortness of breath and chest pain improved after procedure. Pericardial fluid revealed protein 5.4, Glucose 32, LD 458, Amylase 43, Albumin 2.2 with 24,000 WBC, 12,000 RBC, 96 polys, 1 lymph and 3 monos. She remained hemodynamically stable and 2 follow up echo's revealed only a mild pericardial effusion with no signs of tamponade. She was started on colchicine and transfered back to the medical floor on [2195-12-7]. Pericardial [Doctor First Name ], RF, and complement levels were sent and are still pending. . RHEUMATOLOGIC: Underlying history of Sarcoidosis, Sjogren's Syndrome with positive [Doctor First Name ] and dsDNA positive concerning for SLE. She continued on her home dose of Plaquenil. Rheumatology was consulted. Her prednisone was increased to 40mg per day. She was started on Bactrim DS MWF with Calcium and Vitamin D for prophylaxis. She was started on colchicine for her pericardial effusion. She will follow up with Rheumatology as an outpatient to discuss ongoing work-up. CCP and RNP were negative. - Follow up: anti-mitochondrial ab (in setting of LFT abnls and association with Sjogren's - PBC), lupus anticoagulant, anticardiolipin IgG, IgM and beta 2 glycoprotein 1. . ATRIAL FIBRRILLATION: While in the operating room for VATS, she was extubated, requiring re-intubation with subsequent rapid atrial fibrillation with hypotension. Diltiazem drip was started, at which point she remained intubated and was transferred to the ICU. Over the next several hours she improved hemodynamically, converted to sinus rhythm, weaned off diltiazem, restarted beta-blockers and was extubated. Cardiac enzymes were negative. She continued to be in atrial fibrillation throughout her hosptial stay, CHADS2 score 1. She was started on aspirin 81 mg and her metoprolol was titrated up to 100mg tid. . SALMONELLA BACTERMIA: Ms. [Known lastname 102946] was found to have salmonella during her prior admission. She was continued on a full course of ciprofloxacin. She was afebrile at the time of her discharge. - Follow up blood cultures 2 weeks after completing therapy. . INFECTIOUS DISEASES: Pleural effusion pH 7.1 with glucose of 2 confirms likely Parapneumonic effusion. She was started on broad spectrum antibiotics, Vancomycin, and Aztreonam. Ciprofloxacin course for Salmonella bacteremia was continued. Her leukocytosis improved, she remained afebrile, and was pan-cultured with no growth. Pleural cultures from OR tissue grew sparse coag neg staph, but the fluid had no growth to date. It was decided that the staph was likely a contaminant. . HYPERVOLEMIA: The patient's hydrochlorothiazide-triamtere had been held as her creatinine rose to 2.9. As a result she became volume overloaded and experienced shortness of breath and lower extemity swelling. She was discharged on Lasix 40mg daily and should take this for one week. At that point, she should call her PCP and decide if she should switch back to HCTZ-triamterene. . ELEVATED LFTS: She was seen by GI for elevated LFTs which decreased over her hospital course. Abdominal MRI, Abdominal US, MRCP showed Mild central intrahepatic and CBD dilatation without filling defects. They recommended she follow-up as an out patient for underlying liver disease. Hepatic serologies pending. PPI and bowel regimen continued. . RENAL: Acute on Chronic renal failure: ATN peaked to 2.9. With antibiotic dose adjustment and fluids she trend down to her baseline of 1.0-1.6. Her urine output improved. . HEME: Chronic Anemia HCT baseline 26-33. She was transfused 1 unit PRBC on [2195-12-1] for HCT 24 to HCT 26. Sickle test negative. On admission her INR was slightly elevated she was given 3 days of oral vitamin K with normalization of INR. . ENDOCRINE: History of empty sella and high TSH with low thyroid function tests. These should be retested with her PCP as an outpatient who will then decide if she needs to see an endocrinologist. Medications on Admission: 1. ciprofloxacin 500mg PO BID 2. metoprolol Succinate 50 mg daily 3. amlodipine 10 mg daily 4. ASA 81mg 5. Albuterol sulfate HFA 90 mcg/act 8.5 2 puffs every 4-6 hrs prn 6. Albuterol sulfate 2.5mg/3mL Use 1 ampule every 4-6hrs prn 7. prednisone 10mg daily 8. plaquenil 200mg [Hospital1 ] 9. Peg electrolytes 240 g-22.72 Use as directed 10. Loratidine 10mg daily prn:allergies 11. Clonidine 0.1mg [Hospital1 ] 12. triamterene-HCTZ 37mg daily 13. Advair Diskus 500mcg-50mcg 1 inhalation [Hospital1 ] 14. multivitamin : Discharge Medications: 1. prednisone 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily): please continue 40 mg daily, will be tapered to 30 mg daily per rheumatology next week. Disp:60 Tablet(s) Refills:2 2. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) as needed for constipation. 6. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 8. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:60 Tablet(s) Refills:2 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 12. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 13. Calcium-Vitamin D 600-400 mg-unit Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 14. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:20 Tablet(s) Refills:1 15. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO Mon, Wed, Fri. Disp:30 Tablet(s) Refills:2 16. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. Disp:5 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: 1. Left complex parapneumonic effusion, status post VATS 2. pericardial effusion, status post drainage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for a pleural and pericardial effusion. These were drained successfully and the fluid was sent for analysis. Most of these tests are still pending. You went into atrial fibrillation and your metoprolol was increased to control your heart rate. You were started on a baby aspirin to thin your blood and prevent a stroke from your irregular heart rate. It is important that you take this medication daily. In addition, you developed some trouble breathing with low oxygen saturations, likely from fluid overload as your hctz-triamterene was held. You were started on a diuretic to help your leg swelling and fluid overload. The following changes have been made to your medication regimen: - INCREASE metoprolol to 100 mg three times a day - INCREASE prednisone to 40 mg daily, which will be tapered per rheumatology. Prednisone can increase blood sugars, but your sugars have been well controlled to this point. - START bactrim 1 tablet double strength monday, wednesday, friday - START multivitamin - START calcium - START vitamin D - START aspirin 81 mg daily - START lasix 40 mg daily for one week - CONTINUE colchicine 0.6 mg for 5 more days, then stop - STOP clonidine - STOP hydrochlorothiazide-triamterene for one week - RESUME hydrochlorothiazide-triamterene when lasix is discontinued Call Dr.[Name (NI) 2347] office [Telephone/Fax (1) 2348] if you experience: - Fevers > 101 or chills - Increased shortness of breath, cough or chest pain - Incision develops increased pain or redness Please monitor your weights daily. If you notice a change in your weight of greater than or equal to 3 lbs daily, please call your primary care doctor. WOUND CARE RECS: - Chest tube site: remove dressing and cover site with a bandaid until healed - Shower Daily. Wash incision with mild soap, rinse, pat dry - No tub bathing, swimming or hot tub until all incisions healed - No driving while taking narcotics. Take stool softners with narcotics - No lifting greater than 10 pounds - Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30 minutes daily Finally, please discuss your thyroid function tests with your PCP and the possibility of a repeat colonoscopy. Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] [Telephone/Fax (1) 3020] Date/Time:[2195-12-16] 2:00 in the [Hospital Unit Name ] [Last Name (NamePattern1) ] Room 3A Neurosurgery [Location (un) ]. Please get a Chest X-Ray 30 minutes before your appointment in the [Hospital Ward Name 517] Clinical Center [Location (un) ] Radiology. Department: RHEUMATOLOGY When: THURSDAY [2195-12-17] at 10:00 AM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 2226] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) 861] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: [Hospital3 249] When: THURSDAY [2195-12-24] at 2:45 PM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 39446], MD [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] is your new physician in [Name9 (PRE) 191] and Dr. [Last Name (STitle) ] works closely with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [First Name3 (LF) ] both will be involved in your care. For insurance purposes please indicate Dr. [Last Name (STitle) ] as your Primary Care Physician. We are working on a follow up appointment in Rheumatology with Dr. [First Name (STitle) ] [Name (STitle) ] within 2 weeks. The office will contact you at home with an appointment. If you have not heard within 2 business days or have any questions please call [Telephone/Fax (1) 2226].	[ "997.1", "714.0", "416.8", "276.69", "V45.86", "585.2", "493.90", "511.9", "V85.43", "584.5", "710.0", "423.3", "135", "517.8", "427.31", "790.7", "285.29", "278.01", "403.90", "003.8", "710.2", "423.9", "276.2" ]	icd9cm	[ [ [] ] ]	[ "34.04", "34.52", "34.91", "38.97", "88.55", "37.21", "37.0" ]	icd9pcs	[ [ [] ] ]	19528, 19585	11420, 14244	333, 460	19732, 19732	5057, 5059	22110, 23808	3405, 3623		17729, 19505		19606, 19711		17174, 17706		8448, 11397		19883, 22087													3638, 3640									14255, 17148							6401, 8431										256, 295							488, 1648									5073, 6387		19747, 19859						1670, 2992	3008, 3389
28,880	101,090	22744	Discharge summary	report	Admission Date: [2184-11-25] Discharge Date: [2184-12-22] Date of Birth: [2144-12-16] Sex: M Service: SURGERY Allergies: Levaquin Attending:[First Name3 (LF) 668] Chief Complaint: Abdominal and back pain, fever Major Surgical or Invasive Procedure: coil embolization x2 for pseudo-aneurysm of right intrahepatic artery History of Present Illness: 39 M with history of MEN I and multiple procedures including parathyroidectomy, unilateral adrenalectomy, partial pancreatectomy and segment III liver resection ([2184-3-18]) with recent gastrinoma metastisis to liver presented to [Hospital1 18] with fevers to 103 and shoulder/back/abdominal pain. He was in his usual state of health. On [2184-11-17] he underwent radiofrequency ablation of his liver lesion. He did well until [11-25] when he noted worsening pain and fevres. He presented to [Hospital3 ] Hospital where he received antibiotics and was transferred to the [Hospital1 18] for further care. Past Medical History: 1. Gastrinoma and Zollinger-[Doctor Last Name 9480] syndrome 2. MEN 1 syndrome: medical records indicate genetic testing confirmed MEN1 syndrome. Per hx, pt had GERD symptoms in [2172], Abd U/S showed rt adrenal mass. - s/p 3 parathyroid surgeries ([2172]-[2176]) with eventual total parathyroidectomy & reimplant in arm - Unilateral rt adrenalectomy ([11/2174]) at MD [Last Name (Titles) 4223]: pathology demonstrated 7 x 6.5 x 4 cm pheo, adrenocortical hyperplasia, & mult adrenal cortical adenomas. Pt noted to have nl left adrenal at this time. Pre-op urinary mets were 5000, nl urinary catecholamines. - 80% partial pancreatectomy ([11/2174]) at MD [Last Name (Titles) 4223]: for masses in body & tail of pancreas; pre-op gastrin level was 895. Path demonstrated islet cell tumors, immunostaining results not available 3. Type 1 DM: dx'd at age 16 (presenting sx fatigue, polyuria); has h/o DKA; complications include nephropathy. 4. CKD stage II (diabetic nephropathy), baseline creatine 1.4-1.6 5. s/p splenectomy ([11/2174]): done at same time as adrenalectomy and partial pancreatectomy. 6. Gastritis 7. GERD 8. Completion pancreatectomy, segement 3 liver resection [2184-3-18] Social History: He quit smoking in [2182]. He admits to occasional marijuana use. He denies alcohol use. Family History: Father with MEN-->presumably type 1 though this is not stated explicitly in records; medical records indicate he had high gastrin level pre-op and high glucagon s/p Whipple procedure. Mother & sibling are healthy. Cousin w/brain tumor, unknown type. Grandfather died of colon cancer. Physical Exam: On admission: VS: Temp 99.3, HR 109, BP 124/77, RR 20, O2 sat 100% on room air Gen: alert and oriented, stable, tired appearing HEENT: No icterus, no LAD CV: RRR Pulm: clear bilaterally Abd: soft, NT, ND, +BS well healed sub-costal scar Ext: left ankle with 1+non-pitting edema, [3-19] DP/PT pulses On discharge: VS: Temp 101.1, HR 102, BP 117/80, RR 26, O2 sat 94% on room air Gen: alert and oriented, no acute distress, more energetic HEENT: anicteric sclera, no lymphadenopathy CV: RRR, no murmurs, gallops, rubs Pulm: clear bilaterally Abd: soft, nontender, nondistended, palpable hepatomegaly Ext: 1+ edema bilaterally up to knees, 2+ distal pulses Pertinent Results: Discharge labs: [2184-12-22] 04:47AM BLOOD WBC-15.7* RBC-3.29* Hgb-9.0* Hct-29.2* MCV-89 MCH-27.4 MCHC-30.9* RDW-18.5* Plt Ct-863* [2184-12-22] 04:47AM BLOOD Glucose-85 UreaN-16 Creat-1.4* Na-141 K-4.0 Cl-103 HCO3-30 AnGap-12 [2184-12-22] 04:47AM BLOOD ALT-23 AST-28 AlkPhos-331* TotBili-0.8 [2184-12-17] 04:38AM BLOOD Lipase-6 [2184-12-22] 04:47AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.0 [2184-12-19] 05:19AM BLOOD TSH-1.2 CT abdomen/pelvis prior to discharge ([2184-12-21]): 1. No interval change to known subcapsular and intraparenchymal hematomas without CT findings to suggest superinfection. No new fluid collections identified. 2. Resolution of small left pleural effusion with probably stable right pleural effusion, which displaced posterior and medial components. Moderate amount of interstitial septal thickening involving the visualized aerated right lower lobe may reflect interstitial pulmonary edema, however, in conjunction with metastatic left lower lobe pulmonary nodules, lymphangitic carcinomatosis cannot be excluded. 3. Stable left adrenal lesions and post-surgical changes without evidence of bowel obstruction. Brief Hospital Course: Patient was admitted to the [Hospital1 18] on [11-25]. Vancomycin and Zosyn were started. A non-contrast CT abdomen/pelvis was obtained given the patient's renal disease and showed a limited evaluation of the liver parenchyma due to lack of intravenous contrast. Expected post-radiofrequency ablation findings in the right lobe of the liver, a small, nonobstructing left anterior abdominal wall hernia, enlarged, nodular left adrenal gland unchanged since [2184-1-16], multiple enlarged mesenteric lymph nodes unchanged since the prior study, prior pancreatectomy, splenectomy, partial gastrectomy, partial hepatectomy and right adrenalectomy. Overnight on hospital day 1 he was febrile to 103.1 with a significant leukocytosis. He was continued on antibiotics and cultures were sent. On [11-28] RUQ ultrasound was obtained and demonstrated a 6.4 cm heterogeneously echoic lesion within the right lobe of the liver, likely segment VIII, consistent with prior radiofrequency ablation site, a rounded, 1.3 cm vascular area within the radiofrequency ablation site which is suggestive of a pseudoaneurysm. The pseudoaneurysm appeared to arise from an intrahepatic branch of the right hepatic artery. The portal vein was patent. ID service was consulted and patient was switched to meropenem. On [11-28] patient developed worsening abdominal/back pain and became diaphoretic. He was hypotensive with BP 82/70 and relative hypoxia with oxygen saturation of 90 %. He received bolus of NS with good response and was transferred to the ICU for closer monitoring. Patient also had a 4% drop in HCT and was transfused 1 unit of PRBCs without appropriate rise in hematocrit. Central line was placed. 2 more units of PRBCs were administered. Given ultrasound findings, patient was administered bicarb and Mucomyst in preparation for angiography and coil embolization of pseudoaneurysm which he underwent on [2184-11-29]. At the time of the procedure, the pseudoaneurysm appeared to be successfully obliterated with coiling. Post procedure patient developed oliguric renal failure with creatinine peaking around 7. Nephrology service was consulted and he was managed conservatively. He did not require dialysis. Renal failure subsequently resolved with a concomitant fall in creatinine and marked increase in urine output. During this time he continued to have a leukocytosis between 25-38,000 and continued to periodically spike temps. A non-contrast CT scan of the abdomen was obtained on [12-2] and showed increasing size of hyperdensity in the right liver lobe adjacent to the RF ablation and pseudoaneurism embolization site, likely represents presence of a hematoma. Large subcapsular hematoma, compressing the hepatic parenchyma. Since he continued to spike fevers in presence of leukocytosis, there was concern for superinfected hematoma. However, because of the extent of liver damage and size of hematoma, it was deemed unsafe to tap fluid as this could potentially negate the tamponade effect of the capsule and may result in exsanguination. He was managed conservatively and seemed to be stable. Overnight on [12-5] into [12-6] patient developed an acute drop in hematocrit with relative hypotension. [Name2 (NI) ] was transfused 2 units of PRBCs. An urgent RUQ u/s was obtained and showed that the pseudoaneurysm has decreased from [2184-11-29], and there is now a small thrombus. The vessel remained patent, however. Given these findings, patient was once again administered bicarbonate and Mucomyst in preparation for angiography. He underwent repeat coil embolization of pseudoaneurysm on [12-7]. Once again patient developed oliguric ATN approximately 36 hours post procedure. Although fluid intake was minimized he progressively developed respiratory problems with desaturation when supine. CXR revealed a large right sided pleural effusion. This was tapped and drained on [12-9] with successful drainage of 1300 cc of dark, blood-tinged exudative fluid. Initial Gram stain showed 4+ PMNs, but no bacteria and subsequent cultures were negative. ATN subsequently resolved and he started auto-diuresing with improvement in respiratory status. Follow-up U/S on [12-10] showed complete obliteration of pseudoaneurysm. His hematocrits were stable. Leukocytosis persisted as did his fevers. Antibiotics were continued. Superinfection of liver hematoma continued to be of high concern but collection was not drained given high risk of the procedure. He was transferred out of the SICU on [12-14]. TPN was stopped. Kcals were done showing a daily kcal count of ~1300. Nutritional supplements were given. Meropenum was continued for Klebsiella bacteremia (at referring hospital) and subcapsular hematoma. Klebsiella was pan-sensitive. ID recommended at least 3 weeks of treatment using Ertapenum until [1-5]. A picc line was placed on [12-15]. [Last Name (un) ] followed for management of diabetes. He received iv lasix for significant lower extremity edema. On [12-15] a non-contrast CT was repeated showing stable large subcapsular and intraparenchymal hematomas, without evidence of active extravasation. Follow chest x-rays revealed a stable right sided pleural effusion. Psychiatry was consulted to evaluate for depressed mood, tearfullness, and problems with sleep. It was felt that he was dysphoric and recommendations included avoidance of ambien. Ativan was recommended prn at HS. Outpatient psychiatry follow up was discussed with the patient who agreed to think about it. On [12-19], he continued to spike temperatures of 101 to 101.9. A repeat U/A was negative. Blood and urine cultures are negative to date. The possibility of a feeding tube was discussed but he declined this and agreed to eat more and over the last 3 days of his hospital stay he has steadily increased his po intake. He continues to have low grade fevers. A CT scan obtained on [2184-12-21] revealed a stable subcapsular hematoma. He is tolerating a diabetic diet and ambulating regularly. He is discharged home in good condition with VNA to administer IV antibiotics for 2 more weeks. He has appropriate follow up appointments scheduled. Medications on Admission: Lantus 15 qam, humalog SS, protonix 40mg daily, HCTZ 25mg [Hospital1 ], Creon with meals Discharge Medications: 1. PICC Line Care Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. Heparin Flush: dispense # 30 (Thirty) Refills 1 (One) Normal Saline Flush: Dispense #100 (one hundred) Refill 1 (One) box 2. PICC Line Care PICC Line Dressing Kit Change dressing q three days and PRN Dispense # 7 (seven) Refill 1 (One) 3. Ertapenem 1 gram Recon Soln Sig: One (1) Intravenous once a day for 14 doses. Disp:14 units Refills:1 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule, Delayed Release(E.C.) Sig: [5-21] Caps PO QIDWMHS (4 times a day (with meals and at bedtime)). Disp:540 Cap(s) Refills:2 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous once a day. Disp:1 bottle Refills:2 10. Insulin Glargine 100 unit/mL Solution Sig: Three (3) units Subcutaneous at bedtime. 11. Insulin Lispro 100 unit/mL Solution Sig: follow sliding scale Subcutaneous four times a day. Disp:1 Refills:2 Discharge Disposition: Home With Service Facility: [Last Name (un) 6438] Discharge Diagnosis: MEN I Metastatic gastrinoma Klebsiella bacteremia (at referring hospital) Subcapsular liver hematoma s/p RFA with pseudoaneurysm s/p Pseudoaneurysm coil embolization x 2 Acute renal failure Anemia Discharge Condition: good Discharge Instructions: Please call Dr.[Name (NI) 670] office at [Telephone/Fax (1) 673] if you experience: - fever >101.5 - chills - persistent nausea or vomiting - dizziness - abdominal pain not relieved by your medication - inability to eat or drink - any other concerns you may have You will have weekly labs drawn by the visiting nurse [First Name (Titles) ] [Last Name (Titles) 58870] (cbc, bun, creatinine, ast, alt, alk phos, t.bili). The results should be faxed to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1075] in the [Hospital ] clinic at [Telephone/Fax (1) 432]. Followup Instructions: Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2184-12-31] 8:45 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2184-12-31] 1:10	[ "584.5", "719.41", "998.11", "785.52", "995.92", "998.12", "258.01", "585.2", "038.49", "250.41", "285.1", "998.59", "511.9", "442.84", "997.5" ]	icd9cm	[ [ [] ] ]	[ "99.04", "99.15", "39.79", "34.91", "38.93", "88.47" ]	icd9pcs	[ [ [] ] ]	12557, 12613	4574, 10795	301, 373	12854, 12861	3392, 3392	13513, 13789	2411, 2697		10938, 12534		12634, 12833		10821, 10915				12885, 13490					3408, 4551								2712, 2712																	3030, 3373									231, 263							401, 1031									2726, 3016								1053, 2282	2298, 2395
15,150	127,007	14454	Discharge summary	report	Admission Date: [2175-7-25] Discharge Date: [2175-7-28] Date of Birth: [2126-9-30] Sex: M Service: MICU CHIEF COMPLAINT: Post TIPS observation. HISTORY OF PRESENT ILLNESS: The patient is a 48 year-old male with a 1.5 year history of Child's class B cirrhosis complicated by variceal bleeding, refractory ascites and intermittent encephalopathy. He was first diagnosed with hepatitis, felt likely to be alcoholic in origin [2171]. His disease progressed to cirrhosis roughly 1.5 years ago and he had variceal bleeding requiring transfusion and taps. He became jaundice, but this resolved spontaneously. Now he has ascites refractory to diuresis requiring paracentesis roughly every two weeks until the ascites became worse recently. His last tap was two weeks ago and drained 2 liters. There is no history of spontaneous bacterial peritonitis, pruritus, jaundice or emesis now. He does complain of fatigue, mild shortness of breath and anorexia. The patient presented to the [Hospital1 188] transplant service on [2175-7-19] to inquire about his placement on a cadaveric transplant waiting list (MELD score 10) and potential living non-related donor options. The patient was complaining of decreased quality of life due to ascites and a TIPS procedure was performed on [7-26] by interventional radiology. 2500 cubic cm of ascites was drained during the procedure and the second aliquot was slightly bloody. The TIPS procedure was successful per gastroenterology with portal pressures decreasing from 20 mm to 8. Of note a hematocrit obtained on [7-19] was 30.3 and the post procedure hematocrit was 25.1. however, no preprocedure hematocrit was checked. On admission to the Medical Intensive Care Unit the patient complained of thirst and slight neck pain, but stated that his abdomen felt much less distended and painful. PAST MEDICAL HISTORY: Cirrhosis times 1.5 years, hepatitis times four years. Scarlet fever at age 23. Inguinal hernia repaired two years ago. Umbilical hernia one year ago. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives on [Location (un) ] with his wife of two years. No children. Alcohol drank daily for twenty years until roughly one and a half years ago. Denies any history of alcohol abuse or dependence. He does not smoke. Never used intravenous drugs. He has no tattoos. He is not working at the time. FAMILY HISTORY: No liver disease. OUTPATIENT MEDICATIONS: Lasix 40 q day, Spironolactone 200 mg per day. Lactulose titrated to 3 to 4 bowel movements per day. Codeine prn for abdominal distention. PHYSICAL EXAMINATION: Temperature 97.5 degrees. Blood pressure 109/50. Pulse 82. Respiratory rate 22. Oxygen saturation 99% on room air. General supine in bed appears comfortable. Alert and oriented times three. Conversant and appropriate. HEENT normocephalic, atraumatic. Pupils are equal, round and reactive to light bilaterally. Slightly icteric. Oral mucous membranes moist. Pulmonary clear to auscultation bilaterally. Cardiovascular regular rate and rhythm. Normal S1 and S2. No murmurs, rubs or gallops. Abdomen hypoactive bowel sounds, moderately tense and distended abdomen, palpable spleen tip, positive fluid wave, minimally tender, light caput medusa visible. Extremities no clubbing, cyanosis or edema. He does have mild palmar erythema. Also has multiple spider angiomata on extremities, chest and abdomen. Neurological no asterixics. Concentration and memory grossly intact. LABORATORY: On [7-26] post procedure hematocrit was 25.1. On presentation to the Medical Intensive Care Unit white blood cell count was 8.9, hematocrit 28.2, platelets 107. Chem 7 sodium 119, potassium 5.0, chloride 94, bicarb 18, BUN 20, creatinine 0.7, glucose 95, PT 13.9, PTT 34.5, INR 1.4. ALT 44, AST 47, alkaline phosphatase 148, total bilirubin 1.8, calcium 7.8, phosphate 3.7, magnesium 1.9, ascites fluid white blood cell count was 70, red blood cells [Pager number ], glucose 125, total protein 0.5, creatinine 0.6, LDH 24, amylase 37, total bilirubin 0.1, triglycerides 16. Pre-TIPS abdominal ultrasound showed a small irregular liver with large ascites, normal intergrade flow in the main portal vein and hepatic artery and vein. Chest x-ray showed a right internal jugular central line in place. No evidence of pneumothorax and TIPS shunt visible in the upper abdomen. HOSPITAL COURSE: 1. Gastrointestinal: Ascites was subjectively improved after the TIPS procedure per patient. The patient noticed considerable improvement in ascites and abdominal pain. The patient was transfused one unit of packed red blood cells for anemia and for hypovolemia, but without a subsequent bump in hematocrit. Lack of hematocrit bump was felt largely to be due to hemodilution given that particular hematocrit was drawn just after the patient had received 1500 cc normal saline bolus the following morning. We attempted to increase his Lactulose dose titrate to three to five bowel movements every day to decrease his risk of encephalopathy, but the patient refused Lactulose on the 28th, because he was not happy with the Intensive Care Unit toilet facility. The patient never became encephalopathic. A post procedure abdominal ultrasound showed velocities across the TIPS ranging from approximately 100 cm per second proximally to 170 cm per second mid way to approximately 200 cm per second distally. Velocity in the main portal vein was 50 cm per second. There was also a moderate amount of ascites seen. 2. Fluids, electrolytes and nutrition: The patient was hyponatremic to a sodium of 119 on admission to the MICU. The following day sodium was 120. Low sodium was very likely due to cirrhosis, which causes hypovolemic/hyponatremic. The patient did not exhibit signs or symptoms of severe hyponatremia, and his hyponatremia was felt to be long standing. The patient was placed on fluid and sodium restriction to slowly correct his hyponatremia and his sodium on [7-28] had risen to 125. 3. Cardiovascular: The patient remained hemodynamically stable throughout his hospital course, but had declining blood pressure and increasing heart rate the night of [7-27], suggesting intravascular volume depletion. He also had declining urine output during this period. He was bolused 500 cc of normal saline times three on the morning of the 19th with subsequent increase in urine output and blood pressure. 4. Renal: The patient had no evidence of renal dysfunction throughout his hospital stay with creatinine remaining 1.0. However, he did have declining urine output the night of [7-27], which responded well to fluid boluses. 5. Pulmonary: The patient maintained good oxygen saturations on room air. 6. Infectious disease: The patient was afebrile and had a white blood cell count in the normal range and his peritoneal PMN count remained less then 250. Therefore there was no evidence of SBP. 7. Endocrine: Serum glucose remained within normal limits. 8. Neurological: Mental status examination was followed for signs and symptoms of hepatic encephalopathy, but none were found. 9. Prophylaxis: Pneumoboots and Pantoprazole. DISCHARGE CONDITION: The patient was discharged in stable condition to home from the Medical Intensive Care Unit. He will follow up with the [Hospital1 69] Liver Transplant Service in one to two weeks. DISCHARGE DIAGNOSIS: Cirrhosis status post successful TIPS placement. DISCHARGE MEDICATIONS: Lactulose titrated to three to five bowel movements per day. [Doctor Last Name ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], MD [MD Number(1) 5708] Dictated By:[Last Name (NamePattern1) 8228] MEDQUIST36 D: [2175-9-28] 16:10 T: [2175-8-2] 05:55 JOB#: [Job Number ]	[ "789.5", "571.2", "572.3", "572.2", "998.11", "276.1" ]	icd9cm	[ [ [] ] ]	[ "54.91", "39.1" ]	icd9pcs	[ [ [] ] ]				7266, 7453			2456, 2475		7548, 7896		7474, 7524			4467, 7244																													2500, 2642	2665, 4449												151, 175							204, 1889																	1912, 2105	2122, 2439
18,790	167,814	28707+57605	Discharge summary	report+addendum	Unit No: [Numeric Identifier 69416] Admission Date: [2142-8-15] Discharge Date: [2142-9-27] Date of Birth: [2079-1-24] Sex: F Service: [Last Name (un) 7081] DISCHARGE DATE: Anticipated date of discharge: [2142-9-27]. The patient is a 63-year-old woman who was transferred from [Hospital6 ] following admission for new-onset angina followed by cardiac catheterization which revealed significant 3-vessel disease. She was transferred for coronary artery bypass grafting. HISTORY OF PRESENT ILLNESS: A 63-year-old woman complaining of chest pain radiating to her neck and right scapula for the last 6 months. She has had multiple episodes, always triggered by exercise such as walking for 5 to 10 minutes. The pain is accompanied by dyspnea and diaphoresis. She denies nausea or vomiting. EKG at the outside hospital showed T-wave inversions and ST elevations in the anterolateral leads. She was treated initially with Lopressor, aspirin, Plavix and heparin and then brought to the cardiac catheterization lab that showed a left main with no stenosis, LAD that was calcified with diffuse severe proximal disease culminating in a 90% stenosis, circumflex with 70% to 75% proximal stenosis and an 85% stenosis of the OM1, and an RCA that was occluded proximally with the distal RCA filled from left to right collaterals. She also, by report, had reduced LV systolic function and an elevated left ventricular and diastolic pressure. PAST MEDICAL HISTORY: Significant for hypertension, nephrolithiasis, status post lithotripsy. MEDICATIONS AT HOME: Included a multivitamin. ALLERGIES: The patient states no known drug allergies. SOCIAL HISTORY: Lives with daughter. [Name (NI) ] alcohol or drug use. FAMILY HISTORY: No history of CAD. Noncontributory. PHYSICAL EXAMINATION: Vital signs: Temperature 98.4, heart rate 78, blood pressure 107/67. Respiratory rate 20 and O2 saturation 92% on room air and 94% with 2 liters. Neurologic: Alert and oriented x3. No acute distress. Cardiovascular: Regular rate and rhythm, no murmur appreciated. Respiratory: Clear to auscultation bilaterally. No murmurs, rubs or gallops. Abdomen soft and nontender, nondistended with positive bowel sounds. Right groin post-catheterization site without hematoma. Lower extremities: No clubbing cyanosis or edema with 1+ dorsalis pedis pulses. LABORATORY DATA: White count 11, hematocrit 33, platelets 274, INR 1.1, sodium 141, potassium 3.5, chloride 105, CO2 of 26, BUN 9, creatinine 0.6. HOSPITAL COURSE: The patient was stabilized on statin, beta blockers and heparin infusion. On the [10-18], she was brought to the operating room. Please see the OR report for full details. In summary, she had a CABG x4 with a LIMA to the LAD, saphenous vein graft to OM1, saphenous vein graft to OM1, saphenous vein graft to OM2, and saphenous vein graft to PDA. Her cross-clamp time was 98 minutes with a bypass time of 121 minutes. She was transferred from the operating room to the cardiothoracic intensive care unit. At the time of transfer, she had epinephrine at 0.3 mcg per kg per minute and Neo-Synephrine at 0.3 mcg per kg per minute, and a propofol infusion. She was in a sinus rhythm at 86 beats per minute with a mean arterial pressure of 67 and a PAD of 11. In the immediate postoperative period, the patient was hemodynamically unstable. Within hours of arrival in the cardiothoracic intensive care unit, the patient had an intraaortic balloon pump placed at the bedside. A TEE was obtained at that time that showed severe global hypokinesis. The patient was then brought back to the operating room where a repeat catheterization was done. The catheterization showed 100% occlusion of the saphenous vein graft to the RCA and a LIMA to the LAD, a patent saphenous vein graft to OM1 and OM2. They attempted to do a PTCA of the LIMA, however there was significant thrombus and high-grade stenosis at the anastomotic site. They were, however, able to successfully do a PCI of the native LAD, restoring TIMI-3 flow to the native LAD, following which the patient was transferred back to the cardiothoracic intensive care unit. The patient returned from the operating room to the cardiothoracic intensive care unit with epinephrine, milrinone, amiodarone, Neo-Synephrine and lidocaine infusions and continued to have breakthrough ventricular ectopy as well as short bursts of ventricular tachycardia. She remained somewhat hemodynamically stable throughout the operative day. On postoperative day 1, the patient stabilized somewhat. She continued to have occasional episodes of ventricular tachycardia. Her epinephrine infusion was weaned to off. She was continued on amiodarone, lidocaine, Neo-Synephrine and milrinone as well as an intraaortic balloon pump. She was kept sedated throughout this period. On postoperative day 2, the patient continued to make slow progress. Her intraaortic balloon pump was weaned and ultimately discontinued following which the patient had a dip in her mixed venous O2 as well as cardiac index and her epinephrine infusion was reinstituted. Over the next several days, the patient's inotropes were slowly weaned. Sedation was decreased and she was allowed to awake. Her ventilator was weaned to pressure support ventilation. On the [9-21], she was successfully extubated. She did continue, however, to need intermittent episodes of BiPAP to maintain her respiratory status. At the same time, the patient's antiarrhythmics, inotropes and pressors were also slowly being weaned. Despite making progress hemodynamically, the patient continued to be marginal from a pulmonary standpoint, requiring longer and longer duration of her being on BiPAP with less and less time off. Ultimately, she was reintubated on the [10-5]. A bronchoscopy done at that time showed patent airways without significant secretions. The patient also had a central line placed at that time and blood and urine cultures were sent for a persistent white count above 12 with a low-grade fever. A feeding tube was placed and tube feeds were begun. The patient was aggressively diuresed over the next several days in an attempt to get any fluid off prior to an attempt at weaning from the ventilator again. She was again allowed to awaken from sedation, ventilated easily with minimal ventilator support. A repeat bronchoscopy on the 18th again showed patent airways with minimal secretions and mild bronchomalacia. Sputum and blood cultures from earlier showed methicillin-resistant Staph and the patient was begun on vancomycin. An ID consult was obtained at that point in time. All previous lines were re-cited and a thoracic consult was obtained for potential tracheostomy and G tube placement. After several attempts at pressure support wean, the patient underwent a tracheostomy as well as G tube placement on the [10-13]. Please see the OR report for full details. The patient tolerated the procedure well and the following day was able to wean to a tracheostomy collar. The patient remained hemodynamically stable in the cardiothoracic intensive care unit for several more days, not requiring any further ventilatory support. On postoperative day 32 __________ , the patient was transferred to the floor for continuing postoperative care and cardiac rehabilitation. Over the next week, the patient had an uneventful course. She had a PICC line inserted on the [10-19]. She had a left-sided paracentesis on [9-21] for only 300 cc of straw-colored fluid. On [9-26], it was decided that the patient was stable and ready for transfer to rehabilitation. At the time of this dictation, the patient's physical exam is as follows. Vital signs: Temperature 99, heart rate 100, sinus rhythm, blood pressure 109/62. Respiratory rate 30, and O2 saturation 100% on a 21% tracheostomy collar. Weight preoperatively 75.6 kg, at discharge 73.9 kg. Neurologic: Alert, responsive, moves all extremities, follows commands. Pulmonary: Scattered rhonchi with a productive cough. Cardiac: Regular rate and rhythm. Sternum is stable, incision without erythema or drainage. Abdomen is soft and nontender, nondistended, with normal active bowel sounds. The J tube site is clean and dry. Extremities are warm with 1+ pedal edema. Lab data - hematocrit is 29.4. Chemistry - sodium 139, potassium 4.4, chloride 103, CO2 of 30, BUN 20, creatinine 0.8, glucose 121. Chest x-ray with small moderate left effusion and moderate congestive heart failure and bibasilar atelectasis. The patient is to be discharged to an extended care facility. She is to follow up with Dr. __________ 2 to 3 weeks after discharge from rehabilitation. She is also to have followup with Dr. [Last Name (STitle) ] 4 weeks after discharge from rehabilitation. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass grafting x 4 with left internal mammary artery to left anterior descending, saphenous vein graft to obtuse marginal 1, saphenous vein graft to obtuse marginal 2, and saphenous vein graft to the posterior descending artery with a return to the operating room/catheterization laboratory for percutaneous transluminal coronary angioplasty of the left anterior descending artery. 2. Status post tracheostomy and open J tube placement. 3. Status post left-sided pleurocentesis on [8-31] and [9-21]. 4. Methicillin-resistant Staphylococcus aureus positive with blood and sputum cultures. 5. Hypertension. 6. Nephrolithiasis, status post lithotripsy. 7. Hypertension. DISCHARGE MEDICATIONS: Include aspirin 325 mg once a day, potassium chloride 20 mEq once a day, Colace 100 mg b.i.d., Plavix 75 mg once a day, Flovent 2 puffs b.i.d., lisinopril 5 mg once a day, aldactone 25 mg once a day, Combivent 1 to 2 puffs q.6h. as needed, atorvastatin 10 mg once a day, Lasix 40 mg b.i.d., Toprol 50 mg once a day, vancomycin 750 mg IV b.i.d., with the final dose being on [9-30], regular insulin sliding scale, glargine 12 units once a day. Tube feeds were discontinued on the [9-26]. The G tube site to be maintained until repeat calorie count shows adequate nutrition taken orally. Additionally, the patient should have a 1500 cc fluid restriction. [Name6 (MD) 59497] [Name8 (MD) ], MD [MD Number(2) 69417] Dictated By:[Last Name (NamePattern4) 1718] MEDQUIST36 D: [2142-9-26] 11:48:50 T: [2142-9-26] 13:16:47 Job#: [Job Number 69418] Name: [Known lastname 11829],KANEEZ F Unit No: [Numeric Identifier 11830] Admission Date: [2142-8-15] Discharge Date: [2142-9-27] Date of Birth: [2079-1-24] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 265] Addendum: On POD 40 Trach was downsized to #6 Portex cuffed trach without complications and the cuff is deflated. Discharge Disposition: Extended Care Facility: [Hospital3 14] & Rehab Center - [Hospital1 15] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 266] Completed by:[2142-9-27]	[ "996.72", "V09.0", "410.11", "382.00", "518.0", "482.41", "401.9", "414.01", "511.9", "790.7", "518.5", "041.11", "570", "287.5", "427.89", "428.20", "785.51", "599.0" ]	icd9cm	[ [ [] ] ]	[ "34.91", "00.66", "96.6", "00.17", "38.93", "96.04", "99.04", "97.44", "00.40", "46.39", "36.07", "33.24", "31.1", "00.48", "88.57", "39.61", "88.72", "37.61", "99.05", "96.05", "36.15", "88.56", "36.13", "93.90" ]	icd9pcs	[ [ [] ] ]	11020, 11221						1761, 1798	8833, 9584	9608, 10997					2535, 8778											1584, 1667																			1821, 2517																			535, 1466																	1489, 1562	1684, 1744	8803, 8812
68,457	118,480	51429	Discharge summary	report	Admission Date: [2129-8-23] Discharge Date: [2129-9-1] Date of Birth: [2062-6-28] Sex: F Service: MEDICINE Allergies: Aspirin / Compazine Attending:[First Name3 (LF) 45] Chief Complaint: fever, nausea and vomiting blood/coffee grounds Major Surgical or Invasive Procedure: PICC line removal Internal jugular central line placement History of Present Illness: Patient is a 67yo woman admitted from [Hospital1 1501] for fever, nausea, vomiting blood and coffee grouns from rehab. Pt recently admitted to [Hospital1 18] for nosocomial pneumonia, following CABG admission at [Hospital1 18] (CABD performed [2129-7-27]). Patient reports several days of increasing nausea, and subjective fevers, and developed 1.5 days of increasing nausea and vomiting in the days prior to admission. Has had indwelling foley catheter at rehab. Patient reports she may not have had a BM in [5-26] days. Patient originally transferred to the ICU due to multiple medical issues including SBP 200s, and was subsequently transferred to the medical floor for ongoing management. In the ICU, she received IV cipro for a presumed UTI, blood transfusion for upper GI bleed, and IVFs for concern of acute kidney injury. Past Medical History: Medical History signficiant for: Coronary Artery Disease, s/p MI (preserved EF 55% on post-CABG echo) s/p Cerebrovascular accident with L residual hemiparesis ([10-29]) Noninsulin Dependent Diabetes mellitus Chronic kidney disease with microalbuminuria Hyperlipidemia Hypertension Asthma Morbid obesity Past Surgical History: s/p Bilateral carpal tunnel release s/p CABG [2129-7-27]: LIMA-LAD, SVG-OM1, SVG-OM2 ([7-/2129]) Social History: Formerly lives alone, admitted from [Hospital ] rehab s/p CABG on [7-27], discharged from [Hospital1 18] [2129-8-12] Occupation: Nurse [First Name (Titles) ] [Last Name (Titles) 2025], reitred [10-29] after CVA/MI No history of smoking, no EtoH, no ilicit drug use, including no cocaine. Family History: Mother had DM. No known CAD. No history of early MI or blood clot. Physical Exam: On arrival to medical floor: T 98.7 BP 186/65 HR 70 RR 24 Sat 98% on 2L Finger stick BG 159 Gen: Patient in moderate respiratory distress, with dyspnea with and without conversation. Ax0x3 and appropriate. Appears anxious, and reports subjective SOB and anxiety. HEENT: R IJ central line in place with clean dressing, no evidence of surrounding cellulitis. CV: regular, S1S2, no frank murmurs, no tachycardia Lungs: distant breath sounds, increased work of breathing, no wheezes or rhonchi anteriorly, mild rales bilateral bases. Chest wall: midline healing incision, with 3cm x 2cm eschar without evidence of surrounding cellulitis or drainage. No flucutance surrounding eschar. Abd: + bowel sounds, obese, non-distended, firm without rebound or guarding. Ext: L leg with 2+ pitting edema to knee, R leg with 1-2+ pitting edema. Black scar on medial aspect of L knee without evidence of surrounding cellulitis. . On arrival to the [Hospital1 1516] floor VS - 97.7 131/46 56 20 99%2L Gen: Alert, interactive, morbidly obsese female in no acute distress HEENT: Sclera anicteric, oropharynx clear, mmm Neck: JVP ~12cm, supple CV: RRR, nl S1/S2, GII holosystolic murmer at LSB Chest: Mild-moderate respiratory effort, no accessory muscle use, rales to mid-lung fields b/l, no wheezes Abd: Obses, soft, NT/ND, +BS Ext: 2+ pitting edema to knees b/l, 2+ DP pulses b/l Pertinent Results: Pertinent Labs [2129-8-23] 03:38AM BLOOD WBC-8.5 RBC-2.94# Hgb-9.0# Hct-27.6# MCV-94 MCH-30.6 MCHC-32.7 RDW-15.2 Plt Ct-269# [2129-8-23] 11:25AM BLOOD WBC-8.8 RBC-2.80 Hgb-8.9* Hct-26.9* MCV-96 MCH-31.8 MCHC-33.1 RDW-15.1 Plt Ct-262 [2129-8-23] 04:40PM BLOOD WBC-8.6 RBC-2.79* Hgb-8.4* Hct-26.9* MCV-97 MCH-30.2 MCHC-31.2 RDW-14.7 Plt Ct-214 [2129-8-24] 02:45PM BLOOD WBC-9.2 RBC-2.80* Hgb-8.6* Hct-25.8* MCV-92 MCH-30.8 MCHC-33.4 RDW-15.4 Plt Ct-232 [2129-8-25] 06:18AM BLOOD WBC-8.4 RBC-2.63* Hgb-8.0* Hct-24.8* MCV-94 MCH-30.5 MCHC-32.4 RDW-15.1 Plt Ct-211 [2129-8-26] 05:30AM BLOOD WBC-7.9 RBC-2.68* Hgb-8.2* Hct-25.4* MCV-95 MCH-30.5 MCHC-32.1 RDW-15.1 Plt Ct-235 [2129-8-27] 05:02AM BLOOD WBC-7.4 RBC-2.67* Hgb-8.0* Hct-25.8* MCV-97 MCH-30.1 MCHC-31.1 RDW-14.6 Plt Ct-226 [2129-8-28] 04:30AM BLOOD WBC-7.6 RBC-2.63* Hgb-8.3* Hct-24.3* MCV-92 MCH-31.5 MCHC-34.1 RDW-15.3 Plt Ct-221 [2129-8-29] 05:50AM BLOOD WBC-7.4 RBC-2.70* Hgb-8.3* Hct-24.9* MCV-92 MCH-30.7 MCHC-33.2 RDW-15.4 Plt Ct-234 . [2129-8-23] 03:38AM BLOOD Glucose-142* UreaN-77* Creat-2.7* Na-147* K-4.7 Cl-106 HCO3-24 AnGap-22* [2129-8-26] 05:30AM BLOOD Glucose-101* UreaN-81* Creat-3.8* Na-145 K-3.5 Cl-109* HCO3-29 AnGap-11 [2129-8-27] 05:02AM BLOOD Glucose-79 UreaN-76* Creat-3.6* Na-148* K-4.2 Cl-110* HCO3-30 AnGap-12 [2129-8-28] 04:30AM BLOOD Glucose-111* UreaN-74* Creat-3.6* Na-142 K-3.9 Cl-103 HCO3-28 AnGap-15 [2129-8-29] 05:50AM BLOOD Glucose-132* UreaN-76* Creat-3.6* Na-139 K-4.1 Cl-100 HCO3-29 AnGap-14 [2129-8-31] 10:10AM BLOOD Glucose-291* UreaN-72* Creat-2.8* Na-136 K-3.9 Cl-94* HCO3-31 AnGap-15 . [2129-8-23] 03:38AM BLOOD ALT-39 AST-36 LD(LDH)-274* CK(CPK)-81 AlkPhos-162* TotBili-0.6 . [2129-8-23] 03:38AM BLOOD cTropnT-0.10* [2129-8-23] 11:25AM BLOOD CK-MB-6 cTropnT-0.24* [2129-8-23] 04:40PM BLOOD CK-MB-6 cTropnT-0.24* [2129-8-24] 04:03AM BLOOD cTropnT-0.21* . CXR ([8-23]) Patient is status post median sternotomy. Moderately enlarged cardiomediastinal silhouette is stable. Lung volumes are low. No focal consolidation. Trace left effusion. Right-sided PICC has been pulled back, now terminating in the subclavian vein. No pneumothorax. . CXR ([8-23]) PORTABLE AP VIEW OF THE CHEST: There is new left-sided internal jugular central venous catheter which follows a normal course terminating in the distal SVC. No pneumothorax. Chronic severe cardiomegaly, and new increased interstitial markings and engorgement of the central pulmonary vasculature indicate acute cardiac decompensation. Right PICC is unchanged. . CT Chest without contrast IMPRESSION: 1. Small anteroinferior mediastinal fluid collection with no specific features suggestive of abscess formation, although absence of contrast limits assessment for enhancement. Result discussed with Dr [Last Name (STitle) 2026] at time of reporting [2129-8-25]. 2. Bilateral mild to moderately large pleural effusions with associated compressive atelectasis. 3. New right middle lobe 9 x 6 mm nodule which may be secondary to nodular atelectasis, a CT thorax in 6 month's time to ensure stability/resolution is suggested. . CXR ([8-29]) FINDINGS: In comparison with the study of [8-23], there are lower lung volumes. There is continued enlargement of the cardiac silhouette with elevation of pulmonary venous pressure in a patient with intact midline sternal sutures. Left central catheter remains in place. The right PICC line appears to have been removed. . CT Head without contrast ([8-25]) IMPRESSION: No acute intracranial hemorrhage or mass effect identified. To correlate clinically and with ICP for raised intracranial pressure as CT is less sensitive in the early stages and follow up as clinically indicated. . TTE ([8-26]) The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2129-8-9], the estimated pulmonary artery systolic pressure is now lower. The other findings are similar. . Renal US ([8-29]) IMPRESSION: 1. No hydronephrosis. 2. No indication of renal artery stenosis. Lack of diastolic flow in all of the arterial waveforms bilaterally is suggestive of chronic parenchymal disease. Patent renal veins seen bilaterally. . Brief Hospital Course: Hospital course: 1. Upper GI Bleed: Patient with mild Hct decline (to nadir of 23), with report of coffee ground emesis on admission. Likely secondary to [Doctor First Name 329]-[Doctor Last Name ] tear with maybe history of vomiting prior to coffee ground emesis. Her hematocrit had remained stable throughout the hospitilization around her post-CABG baseline. She did not require blood tranfusion. She was on IV pantoprazole 40 mg [Hospital1 ] which was switched to pantoprazole 40 mg po BID on the [Hospital1 1516] floor which was eventually switched to omeprazole 40 mg po BID with concern for proton pump inhibitor induced Acute interstitial nephritis. GI was consulted for endoscopy. They suggested acute medical care of her pulmonary and renal status and no urgent need for endoscopy as patient has had stable Hematocrit. Plavix was held throughout the hospital stay. . 2. Shortness of breath: Likely secondary to pulmonary edema due to aggressive IV fluids in patient admitted with upper GI bleed and Acute Kidney injury. Diuresed on lasix gtt with metalozone 5 mg po BID and eventually switched to IV lasix 40 mg TID with metalozone 5 mg po BID. Her shortness of breath improved with aggressive diuresis. . 3. Acute kidney injury, on chronic kidney disease: Patient with Cr 2.8 today with highest measured at 3.6 during the hospital stay with 2.7 on admission. Likely secondary to Acute interstitial nephritis vs hemodynamic cause. Her creatinine did not respond to fluid resuscitation. All medications were renally dosed and MAP was kept above 65. Renal US did not show any renal artery pathology or intraparenchymal or obstructive pathology. . 4. UTI: Patient had an abnormal Urine analysis with fever on admission . She was treated empirically with 7 days of ciprofloxacin. Her repeat Urine analysis and urine culture were negative. . 5. Constipation: Patient reports not having a bowel movement in one week. She reports passsing gas and does not report abdominal pain. . 6. Intractable nausea: Unsure of the etiology. CT head without contrast was normal. She was initially treated with IV Zofran for her nausea which resolved over the course of her hospital stay. . 7. Non-functioning PICC line: PICC line was not functioning and Alteplase was attempted. IJ line placed for access in the setting of needing access for GI bleed and infection. . 8. DM: Patient on insulin sliding scale on transfer from ICU. Sliding scale insulin was continued on the [Hospital1 1516] service as well. . 9. Right Upper Lobe Nodule Noted incidentally on CT Chest without contrast. Will need repeat imaging in 6 months . 10. Hx of Cerebrovascular accident with L hemiparesis: [4-25] Upper extremity and [3-25] Left upper extremity strength. Along with deconditioning due to her prolong hospital course, PT was consulted while on the [Hospital1 1516] Service. . Medications on Admission: Seroquel 50mg PO qhs Eucerin to LE Hydralazine 25mg PO q6h Amlodipine 10mg PO daily Plavix 75mg PO daily Senna 1tab PO BID Lantus 18units SC qhs Insulin Aspart SS Ramipril 5mg PO daily Rosuvastatin 40mg PO daily Ranitidine 150mg PO daily Clonidine 0.2mg PO TID Metoprolol 12.5mg PO BID Colace 100mg PO BID Bisacodyl 10mg PO daily Lidocaine patch TD 12hrs on, 12hrs off Miralax 17g PO daily Tylenol 650mg PO TID Oxycodone 5mg PO q4h Trazodone 25mg PO qhs prn Lactulose 30cc PO BID prn Ativan 1mg Po q4h prn anxiety NTG 0.4mg PO prn Saline nasal spray q6-8h prn Heparin SC TID Discharge Medications: 1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hours on; 12 hours off. 2. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 6. Metolazone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 8. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. Clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 12. Furosemide 20 mg Tablet Sig: Five (5) Tablet PO BID (2 times a day). 13. Lactulose 10 gram/15 mL Solution Sig: 1000 (1000) MLs PO ONCE (Once) as needed for constipation. 14. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 15. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous once a day. Discharge Disposition: Extended Care Facility: [Hospital ] Hospital - [Hospital1 8] Discharge Diagnosis: Primary Diagnosis 1. Upper gastrointestinal bleed 2. Shortness of breath 3. Acute kidney injury on chronic kidney disease 4. Constipation . Secondary Diagnosis Coronary Artery Disease - s/p CABG [2129-7-27], LIMA-LAD, SVG-OM1, SVG-OM2 s/p Cerebrovascular accident with L hemiparesis Diabetes mellitus Chronic renal insufficiency with microalbuminuria Hyperlipidemia Hypertension Asthma Morbid obesity s/p Bilateral carpal tunnel release 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: Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. You were admitted because you had fever, nausea and coffee ground vomit. You fever, nausea and coffee ground vomit resolved during your hospital stay. You were noted to have kidney damage on admission so you received intravenous fluids which led to short of breath due to fluids in your lung. Fluid was removed from your lung with medications called LASIX and METALOZONE which resolved your shortness of breath. You kidney function stabilized over the course of your hospital stay. You were discharged to rehabilitation facility. . Following changes were made to your medication regimen: START OMEPRAZOLE 40 mg by mouth once a day START LASIX 100 mg by mouth twice a day STOP RANITIDINE 150 mg by mouth two times a day Increase Clonidine to 0.3 mg by mouth three times a day INCREASE HYDRALAZINE to 50 mg by mouth four times a day INCREASE METOPROLOL to 37.5 mg by mouth two times a day . Followup Instructions: Department: CARDIAC SERVICES When: MONDAY [2129-9-12] at 2:00 PM With: [First Name11 (Name Pattern1) 2053] [Last Name (NamePattern4) 2761], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: DIV. OF GASTROENTEROLOGY When: THURSDAY [2129-9-15] at 12:45 PM With: [First Name4 (NamePattern1) 1386] [Last Name (NamePattern1) ], 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 Department: CARDIAC SERVICES When: MONDAY [2129-9-12] at 2:00 PM With: [First Name11 (Name Pattern1) 2053] [Last Name (NamePattern4) 2761], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SURGERY When: MONDAY [2129-9-5] at 2:15 PM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [Telephone/Fax (1) 170] Building: LM [Hospital Unit Name ] [Location (un) 551] Campus: WEST Best Parking: [Doctor First Name ]. GARAGE [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [Doctor First Name 63]	[ "278.01", "518.89", "787.02", "486", "585.9", "599.0", "493.90", "438.20", "530.7", "428.33", "250.00", "584.9", "428.0", "272.4", "404.11", "412", "V45.81", "276.0", "564.09" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	13261, 13332	8446, 8446	325, 385	13817, 13817	3547, 8423	15002, 16380	2075, 2143		11976, 13238		13353, 13796		11376, 11953	8464, 11350			13993, 14979											1619, 1725		2158, 3528																										238, 287							413, 1266											13832, 13969						1288, 1596	1741, 2059
22,029	121,261	44619	Discharge summary	report	Admission Date: [2181-1-12] Discharge Date: [2181-1-18] Date of Birth: [2121-1-4] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 30] Chief Complaint: Emergent ERCP Major Surgical or Invasive Procedure: ERCP with CBD stent placement History of Present Illness: 60 y/o female with severe COPD and cholangitis who developed acute onset RUQ pain 2 months ago with increased WBC and obstructive biliary pattern. MRCP confirmed choledocholithiasis with CBD 11mm and large number of gallstones. Symptoms resolved spontaneously before she was instumented. Underwent elective ERCP early [Month (only) ] which was unsuccessful due to difficulty in passing duodenal papilla. Post procedurally, she developed severe pancreatitis with lipse >1000 and acute epigastic abd pain. Repeat MRCP showed peripancreatic inflammation, dilated CBD with stones. Admitted to ICU and supported with fluids, dopamine, NPO/TPN, narcotics. Started on gatifloxicin for obstructive biliary pattern. Weaned off pressors and pancreatitis resolved. Hosp course complicated by development of pneumonia with MRSA in sputum. Started on vanc. On [2181-1-11] noted to have increased ruq pain with biliary obstructive patter, leukocytosis with bands, and low grade fever. Transferred to [Hospital1 18] for emergent ERCP. Received here and underwent CBD stent placement. Transferred to MICU for observation of cholangitis s/p CBD stent. Afebrile, HD stable, but spO2 85% on room air and mild resp distress. Mild abdominal pain, but diffuse and not particularly tender in RUQ. Baeline COPD is walking 15 feet before stopping to rest. Persantine nuclear scan normal in 10/[2179]. Past Medical History: HTN, hyperchol, hypothyroid, COPD, gallstones, post-ERCP pancreatitis, low back pain Social History: Smoked 3ppd x 40 years. quit 2 1/2 years ago. Lives near cape, home alone, but supportive daughters live nearby Functional of [Name (NI) 5669] and off oxygen at baseline. Worked numerous jobs including hot dog vendor, dog breeder Family History: Uncle w/ emphysema- also smoker 2 daughters w/ hypothyroidism No FH of DM,HTN, or malignancy Physical Exam: PE on admission: T 101.5 BP 121/62 P96 R20 97% on 10 L Gen: mild respiratory distress HEENT: PERRL, MMM. L SC line in place CV: RRR nl s1s2 no MGR Resp: expiratory wheezes with crackles at bases Abd: obese, +BS, TTP RUQ Ext: trace edema Neuro: A+Ox3, follows commands ** PE on transfer ([1-15]): Vitals- T 98.2, BP 150/60, HR 76, RR 20, 88% RA (93%on 8L O2) Gen- well-appearing, NAD, talkative and A&O x 3 HEENT- EOMI. OP clear. no thrush CV- RRR. normal s1/S2. no m/r/g RESP- breathing unlabored. lungs w/ minimal L wheezes, RLL w/ decreased BS + crackle at Base. ABd- obese, soft, NT/ND. NABS. no HSM. Ext- 2+ pedal edema. + clubbing b/l. Neuro- CN II-XII intact. motor strength intact. language fluent. Pertinent Results: Admission Labs [2181-1-12]: 146 108 15 / -------------- 179 3.6 31 0.7 \ Ca: 8.0 Mg: 1.8 P: 3.4 ALT: 129 AP: 385 Tbili: 5.4 Alb: 2.7 AST: 170 LDH: 586 [Doctor First Name ]: 50 Lip: 78 WBC 25.7 HCt 34.5 PLT321 N:87 Band:0 L:10 M:2 E:1 Bas:1 PT: 13.7 PTT: 23.8 INR: 1.2 ABG: pH 7.34 pCO2 54 pO2 93, Lactate 1.4 CBC TREND: [2181-1-13*] WBC-20.4 RBC-3.42* Hgb-10.1* Hct-31.1* Plt Ct-261 [2181-1-14] WBC-18.3* RBC-3.30* Hgb-9.4* Hct-29.9* Plt Ct-308 [2181-1-15] WBC-15.6* RBC-3.36* Hgb-9.6* Hct-30.2* Plt Ct-392 LFT TREND: [2181-1-13] ALT-122* AST-137* Amylase-43 TotBili-4.9* [2181-1-14] ALT-99* AST-60* AlkPhos-322* Amylase-32 TotBili-1.2 [2181-1-15] ALT-70* AST-33 LD(LDH)-380* AlkPhos-264* Amylase-29 TotBili-0.9 [2181-1-16] ALT-65* AST-41* LD(LDH)-434* AlkPhos-225* TotBili-0.8 [2181-1-17] ALT-57* AST-38 AlkPhos-217* TotBili-0.7 Lipase Trend: [2181-1-13] Lipase-63* [2181-1-14] Lipase-42 [2181-1-15] Lipase-46 OTHER LABS: [2181-1-14] %HbA1c-6.6* RADIOLOGIC STUDIES: [1-12] CXR: Right mid and lower lobe opacities. Followup chest radiographs are recommended for further evaluation. [1-14] CXR: Persistent right lung opacities consistent with pneumonia. MICRO DATA: [1-13] Blood Cx- negative [1-13] Urine Cx- negative [1-13] Sputum Cx- [9-11] PMNs and >10 epithelial cells/100X field. Multiple organisms c/w oropharyngeal flora Brief Hospital Course: Brief Hospital Course: 60 y/o female with cholangitis, s/p emergent ERCP with CBD stent. Course complicated by MRSA pneumonia. Symptomatically and clinically improved on antibiotic regimen. 1. Cholangitis - Patient was admitted with fever, increased bilirubin and RUQ pain, and cholangtis was suspected given the patient's history of gallstones. She went to the ERCP lab where numerous filling defects and a 2 cm common bile duct were observed. A stent was placed to relieve the obstruction and due to increasnig respiratory distress the patient was transferred to the MICU post procedure. Levo and flagyl were started on [2181-1-12] for a 10 day course. Her LFT's trended down during the hospitalization and her abdominal exam remained benign. She will have a repeat ERCP in [2-21] wks to remove stent and remnant CBD stones. She should have an elective cholecystectomy soon after cholangitis and pneumonia have resolved completely. She will follow-up with Dr. [Last Name (STitle) 468] in surgery to evaluate for this. 2. Pneumonia/COPD exacerbation - The patient was found to have a RLL/RML infiltrate by chest X-ray and was in respiratory distress post-procedure. Vancomycin was added to her antibiotic regimen as she grew MRSA in her sputum from the OSH. Blood cultures were negative. Her respiratory status gradually improved during her stay in the MICU and she did not require intubation. She was treated with frequent nebulizers, fluticasone, and IV solumedrol as well as a planned 14 day course of vancomycin for her MRSA pneumonia. 14 day course was completed on [2181-1-18]. F/U CXR on [1-16] showed persistent RML/RLL opacities. However, patient had symptomatic improvement and was weaned off oxygen to room air. Productive cough also resolved. Of note her baseline O2 is 86-88% on room air. She will follow-up in clinic in 3 weeks for repeat CXR. 3. Glucose - She was noted to be hyperglycemic during the hospitalization with sugars over 300, in the setting of steroid treatment. She was covered with sliding scale insulin and lantus, which will be tapered over the next 2 weeks. Her hemoglobin A1C of 6.6 suggests borderline diabetes which can be monitored as an outpatient. 4. HTN - normotensive off of anti-hypertensives. held in the setting of recent infection. will consider re-starting as outpatient. 5. Hypothyroid - continued on synthroid 6. Low back pain - treated with percocet 10/650 q8h prn 7. FEN - tolerated PO diet prior to discharge. 8. Code- FULL Medications on Admission: Meds on transfer: Vanco 1g IV q12 Levo 500mg qday Flagyl 500mg [Hospital1 ] Prednisone 60mg daily Pantoprazole 40mg qday Senna Levoxyl 50mcg daily Clotrimazole troche QID Docusate 100mg [Hospital1 ] Hep SC 5,000 TID Albuterol/Ipratropium Nebs. Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 2. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day). Disp:30 Troche(s) Refills:2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:8 Tablet(s) Refills:0 9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:4 Tablet(s) Refills:0 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 11. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed. 12. Prednisone 10 mg Tablets, Dose Pack Sig: see instructions Tablets, Dose Pack PO once a day: 40mg(4tabs)x3days, 30mg(3tabs)x3days, 20mg(2tabs)x3days, 10mg(2tabs)x3days, Stop. Disp:30 Tablets, Dose Pack(s) Refills:0 13. Insulin Regular Human 300 unit/3 mL Syringe Sig: per sliding scale Subcutaneous four times a day. Disp:30 syringes Refills:2 14. Lantus 100 unit/mL Solution Sig: see instructions Subcutaneous at bedtime for 2 weeks: 8 Units/night x 1 week,6 Units/night x 1 week, then stop. Disp:100 Units Refills:0 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. Disp:60 Tablet(s) Refills:0 16. Home Oxygen Dispense oxygen tank and equipment for Home oxygen. Oxygen to be used as needed for shortness of breath or exertion. 17. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ml PO three times a day for 2 doses: while on prednisone . Disp:1 bottle Refills:2 Discharge Disposition: Home With Service Facility: VNA OF [Hospital3 ] Discharge Diagnosis: Primary: 1) Cholangitis with choledocolithiasis and obstruction Secondary: 2) COPD exacerbation, requiring steroids 3) MRSA pneumonia 4) cholangitis s/p biliary stent 5) hyperglycemia attributed to steroids vs. early Type II diabetes 6) Hypothyroidism Discharge Condition: stable Discharge Instructions: If you develop fevers, abdominal pain, yellow skin or eyes contact your physician immediately or go the emergency room. Followup Instructions: Contact Dr. [First Name (STitle) ] [Name (STitle) ] at [Telephone/Fax (1) 1954] or the ERCP/ gastroenterology clinic to schedule a follow up appointment within 2 weeks after you are discharged. You will need to have another ERCP in [2-21] weeks from the time that the stent was placed in your common bile duct. Please follow-up with Dr. [Last Name (STitle) 468] [Telephone/Fax (1) 2835] for a possible gall bladder surgery (to remove the gallbladder). Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 11179] will be your new primary care doctor. You have an appointment in [Hospital6 733] clinic on [2181-2-1] at 1:30pm. Call to confirm your appt at [Telephone/Fax (1) 250]. Dr. [Last Name (STitle) 11179] will refer you for follow-up in Pulmonary clinic for your COPD at that time. You need a repeat Chest X-ray (Dr. [Last Name (STitle) 11179] can arrange) in [2-21] weeks to ensure your pneumonia has completely cleared and your lungs are normal in appearance.	[ "250.00", "401.9", "724.2", "V58.65", "482.41", "V09.0", "518.82", "574.71", "491.21", "576.1", "244.9" ]	icd9cm	[ [ [] ] ]	[ "51.87", "38.93" ]	icd9pcs	[ [ [] ] ]	9454, 9508	4469, 6951	326, 358	9805, 9813	2998, 3975	9981, 11019	2155, 2249		7255, 9431		9529, 9784		6977, 6977				9837, 9958													2264, 2267																										273, 288							386, 1779									2281, 2979								1801, 1887	1903, 2139			6996, 7232		3987, 4423
231	198,608	3414+3415+3416+3451	Discharge summary	report+report+report+report	Admission Date: [2176-5-14] Discharge Date: [2176-6-5] Date of Birth: [2139-8-22] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 36 year old male with HIV, presents [2176-5-14] with intermittent fever, chills, diaphoresis times five weeks, progressive shortness of breath and cough times two to three weeks. Cough is productive of white sputum. He also complains of sore throat, nausea and vomiting times one. The patient was seen at [Hospital 191] clinic on [2176-4-24] and given short course of Bactrim which improved symptoms only temporarily. REVIEW OF SYSTEMS: No headache, neck stiffness, chest pain, orthopnea, edema, abdominal pain, diarrhea, dysuria, rectal or penile discharge, or blood in urine or stool. The patient reports ten pound weight loss over the last five weeks. The patient notes new rash on chest which is non pruritic and nontender. PAST MEDICAL HISTORY: 1.) HIV diagnosed in [2148]. [2176-2-8] CD-4 count was 264. Viral load greater than 100,000. The patient has been on various HAART regimens in the past, complicated by skin reactions. The patient self-discontinued his last regimen about a year ago. The patient denies prior opportunistic infections. 2.) Status post cholecystectomy. MEDICATIONS ON ADMISSION: Tylenol prn. ALLERGIES: HIV medications, unspecified. Reaction is a skin rash. SOCIAL HISTORY: The patient reports smoking one-half pack per day times ten years, none in the past five weeks. He reports social alcohol consumption and occasional cocaine use. The patient is homosexual in a monogamous relationship times five years. The patient is an accountant. PHYSICAL EXAMINATION: On admission, temperature is 98.4; pulse 87; blood pressure 117/60; respiratory rate 24; saturation 95% on room air. General: Thin male, appearing fatigued, tachypneic, no accessory muscle use. The patient is able to speak incomplete sentences. HEAD, EYES, EARS, NOSE AND THROAT: Pupils are equal, round, and reactive to light and accommodation. Sclera anicteric. Oropharynx and tongue with white plaques. Neck: No lymphadenopathy, jugular venous distention or thyromegaly. Cardiac: Regular rate and rhythm, normal S1 and S2, no murmurs, rubs or gallops. Lungs: Bibasilar crackles, rare inspiratory rhonchi, right base. No egophony. Abdomen: Soft, nontender, nondistended, no hepatosplenomegaly, normoactive bowel sounds. Extremities: Warm with no edema and 2+ distal pulses. Skin: Erythematous macular rash over chest and back. No lesions over extremities, palms and soles. LABORATORY DATA: White blood cell count of 10.2; hemoglobin of 12.8; hematocrit of 36.4; platelets 208. Glucose 141; BUN 12; creatinine 0.7; sodium of 129; potassium of 4.3; chloride 93; bicarbonate 24; LDH 712. Chest x-ray with diffuse bilateral increased pulmonary parenchymal opacity. No evidence of pneumothorax or pleural effusion. Soft tissue and osseous structures unremarkable. HOSPITAL COURSE: 1.) Pulmonary: The patient was admitted to [Hospital Unit Name 153] on [2176-6-3] for respiratory decompensation. Started on empiric Bactrim and high dose steroids for PCP. [Name10 (NameIs) ] patient responded well to treatment and was transferred to medical floor on [2176-5-15]. On [2176-5-15], sputum cultures were positive for PCP. [Name10 (NameIs) ] patient's respiratory status decompensated on [2176-5-18] and the patient required transfer to Intensive Care Unit and intubation. He was started empirically on Ganciclovir, Levofloxacin, Flagyl and Ambazone to treat possible coinfection. [2176-5-22] CMV viral load, 812. Ganciclovir was discontinued as low viral count of CMV was felt unlikely to contribute to respiratory status. On [2176-5-22], Levofloxacin, Flagyl and Ambazone were discontinued and Vancomycin was begun to cover possible Methicillin resistant Staphylococcus aureus ventilator associated pneumonia as the patient grew gram positive cocci in sputum. Respiratory status improved and the patient was extubated on [2176-5-25] and Vancomycin was discontinued. On [2176-5-28], the patient with tachypnea and hypoxia with oxygen saturations 88 to 91% on NRB, following possible aspiration. Chest x-ray at that time showed bilateral and fluffy infiltrates. The patient was transferred to Intensive Care Unit and empirically treated with Ceftazidime and Vancomycin. The patient was reintubated on [2176-5-29] for respiratory distress. His respiratory status improved and he was extubated on [2176-5-31] and Ceftazidime and Vancomycin were discontinued at that time as decompensation was felt secondary to a chemical pneumonitis from aspiration rather than super infection. On [2176-5-31], the patient's left subclavian line was removed as the patient had right PICC line placed, after which the patient desaturated to 40% non rebreather and required reintubation. CT angiogram confirmed right lower lobe subsections thrombus and heparin drip was started. The patient's respiratory status improved and the patient was extubated on [2176-6-2] and started on Coumadin on [2176-6-3]. The patient was transferred to the floor on [2176-6-3] where respiratory status has remained good with oxygen saturation 96% on room air at rest, decreasing to 92% on room air with ambulation. At the time of the discharge, the patient remains on heparin as Coumadin is not yet therapeutic. Goal INR of two to three. INR at the time of discharge is 1.2. The patient will be discharged off heparin when Coumadin is therapeutic. At the time of discharge, the patient had completed a 21 day course of Bactrim for PCP pneumonia and had begun Prednisone taper. 2.) Cardiac: Following pulmonary embolism on [2176-5-31], electrocardiogram showed new Q waves in III and AVF with ST elevations in III, AVF, V1, V2. Cardiac enzymes showed CK of 273 and troponin of 0.53. The patient likely had a myocardial infarction in the setting of strain due to a pulmonary embolism, in the setting of prior use of cocaine. Of note, pulmonary embolism occurred while the patient was on subcutaneous heparin. The patient is to follow-up with cardiologist as an outpatient. 3.) HIV: The patient is currently markedly immunocompromised secondary to HIV. The patient was placed on Azithromycin MAC prophylaxis. The patient received a seven day course of Acyclovir for crusty nasal lesions felt consistent with HSV. As mentioned above, low CMV viral load [5-22] at 812 copies, felt noncontributory to pulmonary status. At that time, ophthalmology was consulted and performed dilated funduscopy. At that time, findings were not consistent with CMV retinitis and the patient was taken off Ganciclovir. However, follow-up CMV viral load on [2176-6-3] was 6,690. Infectious disease service felt that Ganciclovir was not warranted at this time and scheduled outpatient follow-up with Dr. [Last Name (STitle) ] [Name (STitle) ]. The patient received repeat CMV viral titers on [2176-6-10] to have results forwarded to Dr. [Last Name (STitle) ]. Dr. [Last Name (STitle) ] will determine whether Ganciclovir should be instituted. The patient received a repeat ophthalmology evaluation on [2176-6-4] which noted normal eye examination, no evidence of CMV retinitis. At this time, the patient remains off any HAART regimens. Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] will institute appropriate regimen as an outpatient. 4.) Fluids, electrolytes and nutrition: The patient noted to have hyponatremia on admission. Sodium remained low throughout admission, reaching nadir at [2176-5-30] of 125. Hyponatremia was thought likely to be due to CIADH based on renal studies as patient had significant pulmonary process. The patient's sodium stabilized at 131 at the time of discharge. The patient will require further follow-up but, as the patient is asymptomatic with stable sodium, no treatment was undertaken at this time. 5.) Gastrointestinal: The patient was noted to have increased amylase and lipase on [2176-5-29] with amylase 703 and lipase of 172. This was felt likely due to Bactrim. The patient remained on Bactrim and amylase and lipase returned to [Location 213] levels at the time of discharge, with amylase of 76 and lipase of 53. At the time of transfer to floor [2176-6-3], the patient was noted to have a four cm, mildly tender right mid abdomen mass. Potential causes include hernia as patient has a history of distant cholecystectomy. However, lymphoma needs to be considered given the patient's immunocompromised status. The patient will be worked up for this mass as an outpatient. 6.) Hematology: The patient was noted to have anemia on admission with hematocrit reaching nadir of 29.8 on [2176-5-23]. However, hematocrit stabilized at 34.7 at the time of discharge. Prior work-up for anemia on [2176-5-18] consistent with anemia of chronic disease. The patient will require further evaluation of anemia as an outpatient with primary care physician. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To acute rehabilitation facility. DISCHARGE DIAGNOSES: Respiratory failure. Pneumocystis carinii pneumonia. Pulmonary embolism. Myocardial infarction. HIV. DISCHARGE MEDICATIONS: Heparin drip on weight base protocol. Guaifenesin 5 to 10 mls p.o. every six hours. Nystatin swish and swallow four times a day. Wolfram 7.5 mg p.o. q h.s. Lansoprazole 30 mg p.o. q. day. Azithromycin 1,200 mg p.o. q. week. Lisinopril 2.5 mg p.o. q. day. Metoprolol 12.5 mg twice a day. ASA 325 mg p.o. q. day. Prednisone 40 mg p.o. q. day times five days, [2176-6-4] to [2176-6-9]. Prednisone 20 mg p.o. q. day times five days, [2176-6-10] to [2176-6-14]. Prednisone 10 mg p.o. q. day times five days, [2176-6-15] to [2176-6-19]. Dulcosate sodium 100 mg p.o. twice a day. Senna 15 mls p.o. q. day. Zolpidem 2.5 mg p.o. q h.s. Albuterol and Atrovent MDI q. six hours prn p.o. q h.s. prn. FOLLOW-UP: The patient is to follow-up with [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] on [2176-6-12] at 11:00 a.m. at [Hospital Ward Name 23] VI at [Hospital1 346]. The patient is to follow-up with Dr. [Last Name (STitle) ] from cardiology on [2184-6-25] a.m. The patient is to follow-up with primary care physician, [First Name8 (NamePattern2) 3403] [Last Name (NamePattern1) ] on [8-10] at 1:15 p.m. The patient will be discharged to rehabilitation facility. The patient will require CMV viral titer on [2176-6-10] with results sent to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. [Doctor Last Name ] [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 5712] Dictated By:[Last Name (NamePattern1) 6008] MEDQUIST36 D: [2176-6-4] 08:46 T: [2176-6-4] 20:55 JOB#: [Job Number 15808] Admission Date: [2176-5-14] Discharge Date: [2176-6-5] Date of Birth: [2139-8-22] Sex: M Service: ACOVE HISTORY OF PRESENT ILLNESS: A 36-year-old male with HIV, CD4 count 264, viral load 100,000 on [2176-2-8], presented [2176-5-14], with intermittent fevers, chills, diaphoresis times five weeks, progressive shortness of breath and cough times two to three weeks. Cough is occasionally productive of white sputum. He also complains of a sore throat, nausea and vomiting. He was seen at [Hospital 191] Clinic [2176-4-24], and given a short course of Bactrim which improved his symptoms temporarily. REVIEW OF SYSTEMS: The patient denies headache, neck stiffness, chest pain, orthopnea, edema, abdominal pain, diarrhea, dysuria, rectal or penile discharge, or blood in urine or stool. He reports ten pound weight loss. He has new rash over his chest which is non-pruritic, non-tender. PAST MEDICAL HISTORY: 1. HIV since approximately [2169]. On [2176-2-8], CD4 264, viral load greater than 100,000. Patient has been on a variety of HAART regimens in the past complicated by skin reactions. He self discontinued his last regimen about a year ago. He denies any opportunistic infections. 2. Status post cholecystectomy. MEDICATIONS ON ADMISSION: Tylenol p.r.n. ALLERGIES: HIV medications unspecified. Reaction is a skin rash. SOCIAL HISTORY: Smoking one-half pack per day times ten years. None in the past five weeks. Patient reports social alcohol use. He also reports occasional cocaine use. He is a homosexual in a monogamous relationship for the last five years. He works as an accountant. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 98.4, pulse 87, blood pressure 117/60, respirations 24, oxygen saturation 95% on room air. General: Tachypneic, no accessory muscle use. Speaking in complete sentences, no acute distress, thin male. HEENT: Pupils equal, round and reactive to light, sclerae anicteric, oropharynx and tongue with white plaques. Neck: No lymphadenopathy, jugular venous distention or thyromegaly. Cardiac: Regular rate and rhythm, normal S1, S2, no murmurs, rubs or gallops. Lungs: Bibasilar crackles, rare inspiratory rhonchi right base, no egophony. Abdomen: Soft, non-distended, non-tender, no hepatosplenomegaly. Normoactive bowel sounds. Extremities: Warm, no edema, 2+ distal pulses. Skin: Erythematous macular rash over chest and back, no lesions in extremities, palms or soles. LABORATORY ON ADMISSION: White blood cell count 10.2, hematocrit 36.4, platelet count 208,000, glucose 141, BUN 12, creatinine 0.7, sodium 129, potassium 4.3, chloride 93, bicarbonate 24, LDH 712. RADIOLOGY: Chest x-ray with bilateral interstitial infiltrates greater on the right than on the left, no cardiomegaly, no pleural effusions. SUMMARY OF HOSPITAL COURSE: 1. Pulmonary: The patient admitted to [Hospital Unit Name 153] [2176-5-14], for increased respiratory distress. Patient started empirically on Bactrim and high dose steroids for PCP pneumonia to which he responded well and was transferred to the floor [2176-5-15]. Sputum culture at that time positive for PCP and patient was continued on Bactrim and steroids. His respiratory status decompensated [2176-5-18], and he required Intensive Care Unit transfer and intubation. The patient was started on ganciclovir to cover positive CMV antibody, levofloxacin, Flagyl and ambazone to treat possible co-infection. CMV viral load from [2176-5-22], 812 ______. Ganciclovir discontinued as given low CMV viral load, CMV was not considered to be a significant contributor to respiratory function. Levofloxacin, Flagyl and ambazone discontinued [2176-5-22], and vancomycin started to cover possible methicillin-resistant Staphylococcus aureus ventilator acquired pneumonia as sputum was positive for Gram positive cocci. Respiratory status improved and patient was extubated [2176-5-25], and vancomycin discontinued. On [2176-5-28], patient presented with increased tachypnea and hypoxia. Oxygen saturation 88-91% on NRB following possible aspiration. Chest x-ray with bilateral fluffy infiltrates. Patient transferred to Intensive Care Unit and started on ceftazidime and vancomycin. Reintubated [2176-5-29], for respiratory distress. Patient extubated [2176-5-31], and ceftazidime and vancomycin discontinued as decompensation felt due to chemical pneumonitis rather than super infection. On [2176-5-31], left subclavian central line was removed as patient had right PICC, after which patient suddenly desaturated to 40% on NRB. Patient was reintubated. CT angiogram confirmed right lower lobe subsegmental thrombus and heparin weight based protocol was started. Patient was extubated [2176-6-2], which he tolerated well. Coumadin started [2176-6-2]. At time of discharge, patient had completed a 21 day course of Bactrim, and status improved. Scheduled for gradual prednisone taper. Oxygen saturation 96% decreasing to 92% with mild activity. 2. Cardiac: Following PE patient's electrocardiogram showed new acute Q-waves in III and aVF with ST elevations in III, aVF, V1, V2. Cardiac enzymes revealed CK 273, troponin 0.53. Patient was already on heparin drip for PE. Myocardial infarction felt secondary to heart strain in setting of PE with history of cocaine use. Cardiac enzymes continued to normalize through hospital stay. Patient to follow up with Cardiology as outpatient. [Doctor Last Name ] [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 5712] Dictated By:[Last Name (NamePattern1) 15809] MEDQUIST36 D: [2176-6-4] 18:23 T: [2176-6-4] 17:35 JOB#: [Job Number 15810] Admission Date: [2176-5-14] Discharge Date: [2176-6-5] Date of Birth: [2139-8-22] Sex: M Service: ACOVE ADDENDUM: On the day of discharge the patient's INR was 3.5. Coumadin dose decreased to 2.5 mg po q day. The patient will be discharged to [Hospital ] Rehab Facility on Coumadin 2.5 mg po q.d. as well as heparin on a weight base protocol. The patient has a follow up appointment with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1461] at [Hospital6 733] at [Hospital1 190] on [6-20] for follow up management. [Doctor Last Name ] [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 5712] Dictated By:[Last Name (NamePattern1) 15811] MEDQUIST36 D: [2176-6-5] 01:34 T: [2176-6-5] 13:46 JOB#: [Job Number 15812] Admission Date: [2176-5-14] Discharge Date: [2176-6-5] Date of Birth: [2139-8-22] Sex: M Service: ACOVE HISTORY OF PRESENT ILLNESS: This is a 36 year old male with HIV who presented on [2176-5-14], with intermittent fevers, chills and diaphoresis times five weeks, progressive shortness of breath and cough times two to three weeks. The cough was productive of white sputum. The patient also reports a sore throat, nausea and vomiting times one. He was seen in [Hospital 191] Clinic on [2176-4-24], and given a short course of Bactrim, which improved his symptoms temporarily. REVIEW OF SYSTEMS: The patient denies headache, neck stiffness, chest pain, orthopnea, edema, abdominal pain, diarrhea, dysuria, erectile or penile discharge, blood in urine or stool. He reports a ten pound weight loss in the last five weeks. He has a new rash over his chest which is non-pruritic and nontender. PAST MEDICAL HISTORY: 1. Human Immunodeficiency Virus diagnosed in [2169]. On [2176-2-8], CD4 264; viral load greater than 100,000. The patient has been on various HAART regimens in the past. Treatment was complicated by skin reactions. The patient self discontinued his last regimen about a year ago secondary to skin rashes. He denies prior opportunistic infections. 2. Status post cholecystectomy. MEDICATIONS ON ADMISSION: 1. Tylenol p.r.n. ALLERGIES: Unspecified HIV medications cause a skin rash. SOCIAL HISTORY: The patient with smoking history of [11-23] pack per day times ten years. No smoking in the last five weeks prior to admission. The patient reports social ethanol use and occasional cocaine use. The patient is a homosexual in a monogamous relationship times five years. He is an accountant. PHYSICAL EXAMINATION: On admission, vital signs are temperature 98.4 F.; pulse 87; blood pressure 117/60; respiratory rate 24; saturation of 95% on room air. In general, a thin male, tachypneic, no accessory muscle use, speaking in complete sentences. HEENT: Pupils are equal, round and reactive to light. Sclerae anicteric. Oropharynx and tongue with white plaques. Neck: No lymphadenopathy, jugular venous distention or thyromegaly. Cardiac: Regular rate and rhythm; normal S1 and S2. No murmurs, rubs or gallops. Lungs: Bibasilar crackles, rare inspiratory rhonchi, right base, no egophony. Abdomen: Soft, nondistended, nontender. No hepatosplenomegaly. Normoactive bowel sounds. Extremities warm, no edema. Two plus distal pulses. Skin: Erythematous macular rash over chest and back. No lesions over extremities, palms or soles. LABORATORY: On admission, hematocrit 36.4, platelets 208, glucose 141, BUN 12, creatinine 0.7. Sodium 129, potassium 4.3, chloride 93, bicarbonate 24, LD 712. Chest x-ray with bilateral diffuse pulmonary interstitial opacities; finding compatible with Pneumocystis carinii pneumonia. HOSPITAL COURSE: 1. PULMONARY: The patient was admitted to [Hospital Unit Name 153] [2176-5-14], due to respiratory decompensation. He was treated empirically with Bactrim and high dose of steroids for PCP [Name Initial (PRE) 1064]. The patient initially responded well to treatment and was transferred to the Floor [2176-5-15]. On [2176-5-15], sputum culture was positive for PCP. [Name10 (NameIs) ] patient's respiratory status decompensated [2176-5-18], requiring Intensive Care Unit transfer and intubation. The patient was started on Ganciclovir, Levofloxacin, Flagyl and Ampicillin, to treat possible co-infection. Ganciclovir was discontinued on [2176-5-27], as CMV viral load 812 copies felt to be not a significant contributor to respiratory decompensation. On [2176-5-22], Levofloxacin, Flagyl and Ampicillin was discontinued and Vancomycin started to cover possible Methicillin resistant Staphylococcus aureus, ventilator associated pneumonia as the patient grew Gram positive cocci in sputum. Respiratory status improved and the patient was extubated on [2176-5-25], and Vancomycin discontinued. On [2176-5-28], the patient with tachypnea and hypoxia with oxygen saturation 88 to 91% on non-rebreather following possible aspiration. The chest x-ray with bilateral fluffy infiltrates. The patient was transferred to the Intensive Care Unit and started on Ceftazidine and Vancomycin. He was re-intubated on [2176-5-29], for respiratory distress. He was extubated [2176-5-31], and ceftazidine and Vancomycin discontinued as decompensation was felt secondary to chemical pneumonitis from aspiration rather than super infection. On [2176-5-31], left subclavian line was removed. The patient had a right PICC line placed. After removal of the left subclavian line, the patient desaturated to 40% on non-rebreather, and the patient was reintubated. A CT angiogram confirmed right lower lobe subsubmental thrombus and heparin drip on weight based protocol was started. The patient's respiratory status improved and the patient was extubated [2176-6-2]. Coumadin was started on [2176-6-3], and the patient was transferred to the Floor on [2176-6-3]. Following transfer to the Floor, the patient's respiratory status remained good. Oxygen saturation 96% on room air at rest, decreasing to 92% with moderate exertion. On the day of discharge, the patient had completed a 21 day course of Bactrim for PCP and had begun a steroid taper. At the time of discharge, the patient was on a heparin drip and Coumadin 7.5 mg p.o. q. h.s. for goal INR of 2.0 to 3.0. At the time of discharge, INR was 1.2. The patient will continue Coumadin for six months. 2. MYOCARDIAL INFARCTION: Following pulmonary embolism [2176-5-31], EKG with new Q in III and AVF with ST elevations in III, AVF, V1, V2. Cardiac enzymes were CK 273, troponin 0.53. As the patient was already on heparin, no further cardiac treatment was started. Cardiac enzymes continued to normalize throughout the remainder of his hospital stay. The patient will follow-up with Cardiologist as an outpatient. On [2176-6-3], an echocardiogram showed a normal left atrium, no atrial septal defect, left ventricular ejection fraction of 70%; dilated right ventricle with decrease in function, trivial mitral regurgitation, no pericardial effusion. For cardiac function, the patient was started on Metoprolol and Lisinopril. 3. HUMAN IMMUNODEFICIENCY VIRUS: The patient was started on Azithromycin for MAC prophylaxis. The patient received a ten day course of Acyclovir for crusting on nares felt to be likely herpes. The Infectious Disease Team decided to wait to start HAART regimen until the patient had been extubated for at least a week. The patient is to follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] as an outpatient who will start an HAART regimen. As mentioned above, ganciclovir had been discontinued on [2176-5-22], due to low viral load. On [2176-6-4], CMV 6690. Infectious Disease Service recommended holding adding ganciclovir for now. The patient to follow-up with Dr. [Last Name (STitle) ] an outpatient. The patient will have CMV viral titer drawn in one week post discharge and Dr. [Last Name (STitle) ] will decide if Ganciclovir is warranted. The patient received an Ophthalmology consultation on [2176-5-31], to rule out CMV retinitis and CMV retinitis was felt unlikely. Given increase in CMV viral load at time of discharge, Ophthalmology reconsulted. Recommendations were pending at time of discharge. 4. HYPONATREMIA: The patient with low sodium throughout admission, reaching a nadir on [2176-5-30], at 125. Renal studies were consistent with syndrome of inappropriate diuretic hormone. This was felt secondary to a pulmonary process. The patient's sodium stabilized at 131 and as the patient was asymptomatic, no further treatment was pursued. 5. ANEMIA: The patient was noted to have an anemia ranging at 26 to 34 during current admission. Iron studies were consistent with anemia of chronic disease. Hematocrit stabilized at the time of discharge to 34.7. 6. PANCREATITIS: The patient noted to have elevated amylase and lipase on [2176-5-29]; amylase was 204 and lipase 172. The patient was asymptomatic and pancreatitis was felt secondary to Bactrim. Although Bactrim was continued, amylase and lipase normalized to lipase of 53 and lipase was 76 at time of discharge. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To acute rehabilitation facility. DISCHARGE DIAGNOSES: 1. Acute respiratory failure. 2. Pneumocystis carinii pneumonia. 3. Myocardial infarction. 4. Pulmonary embolism. 5. Human Immunodeficiency Virus. DISCHARGE MEDICATIONS: 1. Heparin drip on weight based protocol. 2. Guaifenesin 5 to 10 ml p.o. q. six hours. 3. Nystatin 100 [Doctor Last Name ] per ml oral suspension, 5 ml four times a day. 4. Albuterol and Atrovent MDI, two puffs q. six hours p.r.n. Shortness of breath or wheezing. 5. Zolpidem 5 mg p.o. q. h.s. p.r.n. insomnia. 6. Docusate sodium 100 mg p.o. twice a day. 7. Prednisone 40 mg p.o. q. day times five days; [2176-6-4] until [2176-6-9]. 8. Prednisone 20 mg p.o. q. day times five days; [2176-6-10] until [2176-6-14]. 9. Prednisone 10 mg p.o. q. day times five days; [2176-6-15] until [2176-6-19]. 10. Warfarin 5 mg p.o. q. h.s. 11. Lantoprazol 30 mg p.o. q. day. 12. Azithromycin 1200 mg p.o. q. week. 13. Lisinopril 2.5 mg p.o. q. day. 14. Metoprolol 12.5 mg twice a day. 15. ASA 325 mg p.o. q. day. DISCHARGE INSTRUCTIONS: 1. The patient to be discharged to acute rehabilitation facility. 2. The patient is to follow-up with primary care physician. [Doctor Last Name ] [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 5712] Dictated By:[Last Name (NamePattern1) 14605] MEDQUIST36 D: [2176-6-4] 19:12 T: [2176-6-14] 16:34 JOB#: [Job Number 15918]	[ "410.71", "518.81", "253.6", "577.0", "042", "136.3", "507.0", "078.5", "482.41" ]	icd9cm	[ [ [] ] ]	[ "38.91", "96.72", "96.6", "33.24", "38.93", "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]								26295, 26448	26471, 27306				19087, 19168	20648, 26184			27330, 27724																							13917, 17837				19510, 20631							18348, 18645												17867, 18328									13573, 13889								18667, 19061	19186, 19486	26210, 26274
13,179	161,779	14119	Discharge summary	report	Admission Date: [2119-2-20] Discharge Date: [2119-3-1] Date of Birth: [2067-8-18] Sex: M Service: CARDIOTHORACIC Allergies: Zestril Attending:[First Name3 (LF) 1283] Chief Complaint: known heart murmur with mild shortness of breath and chest tightness Major Surgical or Invasive Procedure: s/p aortic valve replacement(23mm St. [Male First Name (un) 923] mechanical) History of Present Illness: Mr. [Known lastname 11270] is a 51 yo gentleman with a [4-4] month h/o shortness of breath and chest tightness> He was found to have aortic stenosis on echocardiogram. Past Medical History: aortic stenosis Type 2 DM HTN hypercholesterolemia s/p L fem bypass [2095] s/p MVA with multiple orthopedic injuries nephrolitihiasis Pertinent Results: [2119-2-28] 06:50AM BLOOD WBC-10.7 RBC-3.45* Hgb-10.0* Hct-31.2* MCV-91 MCH-29.1 MCHC-32.2 RDW-14.6 Plt Ct-352 [2119-3-1] 06:15AM BLOOD PT-18.1* PTT-60.1* INR(PT)-2.1 [2119-2-28] 06:50AM BLOOD Plt Ct-352 [2119-2-28] 06:50AM BLOOD Glucose-127* UreaN-13 Creat-0.8 Na-140 K-4.9 Cl-103 HCO3-27 AnGap-15 Brief Hospital Course: Mr. [Known lastname 11270] was admitted to [Hospital1 18] on [2119-2-20] and taken to the operating room with Dr.[Last Name (STitle) ] for an AVR with a [Street Address(2) 11688]. [Male First Name (un) 923] mechanical valve. He tolerated the procedure well and was transferred to the ICU in stable condition. He was weaned and extubated from mechanical ventilation on his first post operative night. Post operatively the patient had a period of junctional rhythm which resolved by POD#2 and the patient was started on a beta blocker without difficulty. On POD#1 he was noted to have some mild abdominal distention which resolved with Reglan. On POD#3 he began complaining of difficulty breathing which he thought was due to anxiety. His CXR was unremarkable and it was felt that his respiratory issues were truly anxiety. He was started on Ativan, which he was taking at home, and a PCA for pain control, but the patient continued to have episodes of panic attacks. A psychiatry consult was obtained and recommended continuing the Ativan and adding trazodone and Zyprexa which were added with good control of anxiety, an subsequently changed to Remeron. The psychiatry service discussed their findings with the patient's PCP and recommended follow up for the patient. The team also counseled the patient on minimizing his alcohol consumption. During this time the patient also developed atrial fibrillation and an EP consult was obtained due to his prior junctional rhythm. It was recommended to control the atrial fibrillation with Lopressor and no amiodarone. The patient had been started on anticoagulation for his mechanical valve. He continued to progress well with physical therapy, no further episodes of atrial fibrillation were noted, and by POD#9, his INR was 2.1 and he was cleared for discharge to home. Medications on Admission: Norvasc 10mg qd Accupril 40mg qd Crestor 10mg qd Celebrex qd gulcatrol 5mg qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Rosuvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:100 Tablet(s) Refills:0 6. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:50 Tablet(s) Refills:0 7. Quinapril HCl 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:0 10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:20 Tablet(s) Refills:0 11. Coumadin 5 mg Tablet Sig: as directed Tablet PO once a day: take 10mg [3-1] then per Dr.[Name (NI) 42076] office. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Type 2 DM HTN aortic stenosis s/p AVR dyslipidemia anxiety/depression post operative atrial fibrillation Discharge Condition: good Discharge Instructions: you may take a shower and wash your incisions with mild soap and water do not swim or take a bath for 1 month do not drive for 1 month do not apply lotions, creams, ointments or powders to your incisions do not lift anything heavier than 10 pounds for 1 month do not drink alcohol while taking pain mediciations Followup Instructions: follow up with Dr.[Name (NI) 42076] office by phone [3-2] for coumadin dosing follow up with Dr. [Last Name (STitle) ] in [1-1] weeks follow up with Dr. [Last Name (STitle) ] in [1-1] weeks follow up with Dr. [Last Name (STitle) ] in [3-3] weeks Completed by:[2119-3-1]	[ "401.9", "250.00", "272.0", "V13.01", "427.31", "997.1", "424.1", "300.4" ]	icd9cm	[ [ [] ] ]	[ "99.04", "35.22", "39.61" ]	icd9pcs	[ [ [] ] ]	4458, 4513	1151, 3004	342, 425	4662, 4668	812, 1128	5028, 5336			3132, 4435		4534, 4641		3030, 3109				4692, 5005																																							234, 304							453, 631																	653, 793
25,384	162,154	26392	Discharge summary	report	Admission Date: [2182-1-18] Discharge Date: [2182-1-21] Date of Birth: [2128-8-31] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 898] Chief Complaint: Transfer from [Hospital1 ] [Location (un) 620] for diabetic ketoacidosis Major Surgical or Invasive Procedure: None History of Present Illness: 53 year-old man with history of Type I diabetes and ETOH abuse transferred from [Hospital1 ] [Location (un) 620] for DKA. At noon the day prior to admission, the patient forgot to take his home dose of lantus (40 units). At 11 p.m. that night, he drank 2 glasses of vodka (normally drinks a pint of vodka per day). He awoke at 2 a.m. the day of admission with nausea/vomiting. At 8 a.m., he checked his blood sugar, which was >400, for which he reports he took 80 units of humalog. At his daughter's insistence, he went to [Hospital1 ] [Location (un) 620] where his blood glucose was 481, anion gap 36, and bicarbonate <5, creatinine 2.4. ABG was obtained, with pH 6.91, pCO2 18, pO2 107. He was started on an insulin drip and received 2 amps of sodium bicarbonate, 10 L NS, and anzemet prior to transfer to [Hospital1 18]. ROS: Notable for nervousness, shakiness, dysuria, increased urinary frequency, "greasy stuff" in stool. Past Medical History: 1. Alcohol abuse: h/o withdrawal seizures and alcoholic hepatitis. Drinks 1 pint of vodka daily 2. DM (presumed type 1, given w/ h/o DKA in past) 3. Hypercholesterolemia 4. GERD Social History: Drinks 1 pint vodka/day. Nonsmoker with no history of IV drug use. Previously inhaled heroin and cocaine, quit >10 years ago Family History: Noncontributory Physical Exam: Temp 98.4, HR 117, bp 118/59, resp 20, O2 sat 99% RA Gen: Midddle aged male, appearing mildly nervous, alert, NAD HEENT: PERRLA, right subconjunctival hemorrhage, EOMI, OMMM, herpetic lesion inner lip, crusted blood noted at back of throat Lungs: CTAB Cardiac: tachycardic, regular, no murmurs noted Abd: NABS, soft, mildly distended, mild tenderness in RUQ w/o rebound/guarding Ext: warm X 4 w/good sensation in feet, no edema Neuro: A&O X 3, moving all 4 ext, nl speech Pertinent Results: Labs on admission: [2182-1-18]: GLUCOSE-156 UREA N-18 CREAT-1.3 SODIUM-139 POTASSIUM-4.9 CHLORIDE-107 TOTAL CO2-11 ALT(SGPT)-33 AST(SGOT)-63 LD(LDH)-213 CK(CPK)-209 ALK PHOS-119 AMYLASE-109 TOT BILI-0.8, LIPASE-124 CK-MB-5 cTropnT-<0.01 ALBUMIN-3.6 CALCIUM-6.8 PHOSPHATE-1.6 MAGNESIUM-1.2 ACETONE-LARGE WBC-9.2 RBC-3.35 HGB-11.1 HCT-30.9 MCV-92 MCH-33.1 MCHC-35.8 RDW-13.4 NEUTS-89.1 BANDS-0 LYMPHS-6.2 MONOS-4.5 EOS-0.1 BASOS-0.0 PLT COUNT-184 PT-13.3 PTT-25.6 INR(PT)-1.2 EKG [2182-1-18]: sinus tachycardia at 115 bpm, no STTW changes CXR [2182-1-18]: No acute cardiopulmonary process Brief Hospital Course: 53 year old male with history of alcoholism and Type I diabetes presents with DKA in the setting of heavy alcohol use and missed insulin dose. 1) DKA: Likely precipitated by missed lantus dose in the setting of heavy alcohol use. An infectious work-up was undertaken, with negative urine cultures, blood cultures, and chest X-ray. The patient was initially admitted to the MICU on an insulin drip until his anion gap normalized, at which time he was restarted on his home dose of lantus. His electrolytes, including potassium, phosphate, and magnesium wer aggressively repleted. He was transferred to the general medical floor on [2182-1-20]. On that evening, he had a asymptomatic hypoglycemic event (blood glucose 25 at 4 a.m.). The patient insisted on leaving the hospital against medical advice on [2182-1-21], despite being informed of the risks of hypoglycemia. An urgent [Last Name (un) ] appointment was scheduled and he agreed to follow-up with his PCP [Last Name (NamePattern4) ] [1-14] days. 2) Alcohol abuse: The patient received several doses of valium, followed by a CIWA scale and was closely monitored for evidence of withdrawal. He also received thiamine and folate. He was evaluated by addiction services, who provided him with a information regarding outpatient treatment/resources. 3) RUQ pain: This was most likely secondary to mild alcoholic hepatitis/pancreatitis. RUQ ultrasound at [Hospital1 ] [Location (un) 620] prior to transfer was without evidence of cholecystitis. His pain resolved over the course of his hospital stay.. 4) Acute renal failure: With aggressive hydration, the patient's creatinine normalized to 0.7 from 2.4 at [Location (un) 620] prior to transfer, indicating that his acute renal failure likely reflected a pre-renal state in the setting of DKA. 5) Full Code Medications on Admission: Lantus 40 units daily Humalog insulin sliding scale Lipitor 20 mg PO daily Flomax 0.4 mg PO daily ASA 325 mg PO daily Prilosec 20 mg PO daily "Herpes medication" Discharge Medications: 1. Lantus 100 unit/mL Solution Sig: Forty (40) units Subcutaneous at bedtime. 2. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous before each meal and at bedtime: Please resume prior sliding scale. 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: Diabetic Ketoacidosis Secondary: type I diabetes, alcohol abuse, hypercholesterolemia reflux Discharge Condition: Patient is signing out against medical advice. Discharge Instructions: Mr. [Known lastname ] is leaving the hospital AMA. He understands the risks of doing so and accepts these risks. Please check your fingersticks before each meal and before bedtime. Please set an alarm for 3 a.m. to check your fingerstick, as you have been hypoglycemic while in the hospital. Your are encouraged to stop drinking alcohol. You have been provided with information regarding community support programs. Followup Instructions: 1) Primary Care Please call your PCP (Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5057] [Telephone/Fax (1) 5763]) to be seen within 1-2 days following discharge 2) Endocrinology [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 2378]) Wednesday [2182-1-30] 10:30 a.m. Completed by:[2182-5-22]	[ "530.81", "577.0", "272.0", "303.91", "584.9", "250.12" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	5821, 5827	2892, 4739	395, 402	5973, 6022	2266, 2271	6492, 6862	1741, 1758		4951, 5798		5848, 5952		4765, 4928				6046, 6469													1773, 2247																										275, 357							430, 1381									2285, 2869								1403, 1582	1598, 1725

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