Split (1)

train · 26.9k rows

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55,920	174,733	52865	Discharge summary	report	Admission Date: [2182-8-22] Discharge Date: [2182-9-12] Date of Birth: [2121-3-14] Sex: M Service: CARDIOTHORACIC Allergies: Vancomycin Analogues / Histamine / Ciprofloxacin / Penicillins / Cephalosporins / Atorvastatin / Rosuvastatin Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea, weakness Major Surgical or Invasive Procedure: OPERATION PERFORMED: 1. Coronary artery bypass grafting x3, with a left internal mammary artery graft to the left anterior descending and reversed saphenous vein graft to the marginal graft and the right coronary artery. 2. Mitral valve repair with a 30-mm Physio II annuloplasty ring. History of Present Illness: 61M complicated hx including Diabetes,Dyslipidemia,Hypertension Afib s/p failed cardioversion on coumadin and amiodarone, Dilated cardiomyopathy, sCHF with EF of 25-30%, severe 3+ MR, PFO, CAD, severe pulmonary hypertension on sidafenil, and CKD p/w complaints of worsening dyspnea over the past 4-5 days. Per the patient, has been doing well with rehabilitation, walking up to [1-6] mile per day and "getting stronger everyday". Woke up around Sunday morning, stating his legs were extremely week. In addition, he felt he was more SOB and having worsening chest pain. On the day of presentation, his VNA saw him and noted increased work of breathing. He denied fever, cough, nausea, vomiting, diaphoresis, abdominal pain, although did attest to right LE swelling with B/L LE pain (aching). He does have 4 pillow orthopnea which has been stable since he was discharged one month ago (was admitted here and found to have pulmonary hypertension) as well as PND, though no lower extremity swelling at baseline. Denies any recent trips. Has been compliant with low sodium/low fluid diet. Called Dr. [First Name (STitle) 437] today and spoke with [Doctor First Name ] Nestory, who recommended the patient present to the hospital. Of note, was scheduled for surgery [2182-8-28] for MV replacement as well as PFO correction and CABG. . In the ED, initial vitals were T99 HR89 BP136/86 RR18 98% RA. EKG showed sr 88, lad, 1st deg avb, ivcd, STD V4/5 [Doctor Last Name ] to prior, no stemi with scattered pvcs. Labs were significant for WBC of 10.6 (baseline), HCT of 33 with microcytosis of 80 for MCV (baseline since [2182-7-5]), Creatinine of 1.7 (baseline), proBNP of 3699 (last value of 8480 in [4-/2182]), troponin of 0.08 (baseline since [4-/2182]), INR of 2.4. CXR showed mild engorgement of central pulmonary vasculature as well as scattered lines denoting intralobular thickening with an impression of pulmonary edema likely cardiogenic in etiology. Vitals prior to transfer were 99.1 91 124/83 22 100%2l. . On the floor the patient is c/o chest pain (at baseline). Otherwise NAD, but feels generally unwell. Past Medical History: 1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: - Afib s/p failed cardioversion on coumadin - Dilated cardiomyopathy, non-ischemic - CAD - CHF (EF 25-35%) - PFO 3. OTHER PAST MEDICAL HISTORY: - severe pulmonary hypertension on sidafenil - CKD with baseline Cr - CVA in [2175]--L sided facial droop - Osteoarthritis. - Depression. - Hx of Hodgkin's disease s/p surgical excision and CTX at age 18 . PAST SURGICAL HISTORY: 1. Appendectomy. 2. Hernia repair. 3. Back surgery after falling from 36 feet. 4. Multiple operations on his left knee and his right knee. 5. Multiple abdominal surgeries, first to remove small bowel polyps and then followed by surgeries to fix complications of previous surgeries. 6. Lymph node removal from the groin that was infected Social History: He lives with his sister and her family. States there is always someone home. He has 3 children, including a 6 yr old son who live in [Name (NI) ]. He used to be an avid athlete, running > 12 miles daily but due to progressive heart failure, develops symptoms of fatigue/ dyspnea with minimal exertion denies current tobacco, ETOH, IVDA Family History: Father had 1st heart attack at 35 then died of MI at 45. Mom with DM2, died of AAA rupture. Physical Exam: Physical Exam Pulse:73 Resp:20 O2 sat: 98% on 2Lpm nc B/P 108/76 Height:5'[81]" Weight:187.4 Five Meter Walk Test #1_______ #2 _________ #3_________ General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] __1+(B)LE Varicosities: None [x] Neuro: Grossly intact [x](L) sided facial droop resolved Pulses: Femoral Right: Left: DP Right:2+ Left:2+ PT [Name (NI) 167]: Left: Radial Right: Left: Carotid Bruit-none, pulse Right:2+ Left:2+ Pertinent Results: CAROTID DUPLEX ([8-23]): 1. There is no evidence of significant carotid artery stenosis bilaterally. 2. Atherosclerotic plaques in the carotid bulbs and internal carotid arteries bilaterally. . PANOREX TEETH AND MANDIBLE ([8-23]; handwritten note): 4x6mm asymmetric nodule under angle of left mandible. Would recommend repeat read by radiologist. Otherwise unremarkable . CHEST X-RAY ([2182-8-23]) FINDINGS: Mild engorgement of the central pulmonary vasculature is identified. There is minimal prominence of the interstitial markings. Few scattered lines are denoting interlobular septal thickening identified at the bases. The mediastinum is otherwise unremarkable. The cardiac silhouette is enlarged but stable. No definite effusion or pneumothorax is noted. Degenerative changes are seen throughout the mid and lower thoracic spine and in the included left acromioclavicular joint. IMPRESSION: Mild prominence of the interstitial markings may indicate mild early edema, likely cardiogenic in etiology. . RIGHT HEART CATHETERIZATION ([2182-8-29]): 1. Severe pulmonary hypertension. 2. Moderately elevated left sided filling pressures. 3. Minimally elevated RA pressure. 4. Preserved cardiac output. 5. Slight response to nitric oxide in addition to 100% O2, sildenafil, and nifedipine (last dose given evening prior to AM test). PVR decreased from 6.5 to 5.7. . ECHOCARDIOGRAM ([8-29]): IMPRESSION: Moderately dilated left ventricle with mild symmetric left ventricular hypertrophy and severely depressed left ventricular systolic function with regional wall motion abnormalities as described above. Mildly dilated aortic root and ascending aorta. Mild aortic regurgitation. Moderate to severe mitral regurgitation. Severe pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [2182-8-12], the previously noted noncoronary sinus of Valsalva aneurysm is not clearly visualized. The peak pulmonary artery systolic pressure has increased from 70 mmHg to 80 mmHg. . [2182-9-10] 05:09AM BLOOD WBC-11.4* RBC-3.39* Hgb-9.5* Hct-28.5* MCV-84 MCH-28.1 MCHC-33.4 RDW-16.2* Plt Ct-308 [2182-9-9] 05:12AM BLOOD WBC-12.0* RBC-3.38* Hgb-9.6* Hct-28.5* MCV-84 MCH-28.4 MCHC-33.7 RDW-16.0* Plt Ct-264 [2182-9-10] 05:09AM BLOOD Neuts-80.1* Lymphs-12.2* Monos-5.0 Eos-2.6 Baso-0.2 [2182-9-10] 05:09AM BLOOD Plt Ct-308 [2182-9-10] 05:09AM BLOOD PT-17.0* PTT-29.3 INR(PT)-1.5* [2182-9-9] 05:12AM BLOOD Plt Ct-264 [2182-9-9] 05:12AM BLOOD PT-16.4* PTT-26.7 INR(PT)-1.5* [2182-9-10] 05:09AM BLOOD Glucose-108* UreaN-49* Creat-1.7* Na-138 K-4.1 Cl-97 HCO3-30 AnGap-15 [2182-9-9] 07:00AM BLOOD Glucose-121* UreaN-45* Creat-1.7* Na-137 K-4.1 Cl-96 HCO3-32 AnGap-13 [2182-9-10] 05:09AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.6 [2182-9-9] 07:00AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.3 Brief Hospital Course: The patient was brought to the operating room on [9-2] where he underwent coronary artery bypass grafting x3, with a left internal mammary artery graft to the left anterior descending and reversed saphenous vein graft to the marginal graft and the right coronary artery and mitral valve repair with a 30-mm Physio II annuloplasty ring as well as a closure of a patent foramen ovale. The patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. The patient was electivly kept intubated overnight due to elevated pulmonary artery pressures, but eventually extubated on post operative day #1. The patient was neurologically intact and hemodynamically stable, but remained on milrinone until post operative day number 2 and dobutamine was weaned to 2.5 on day 4 and eventually stopped on post operative day 6. Coreg was started and titrated up for chronic systolic heart failure. Lisinopril to be started when creatinine stabilizes per cardiologist Dr. [First Name (STitle) 437]. The patient was gently diuresed toward his preoperative weight. The patient was transferred to the telemetry floor for further recovery on post operative day 8 ([2182-9-10]). Chest tubes and pacing wires were discontinued without complication. He was placed on macrodantin for a urinary tract infection. His coumadin was restarted for chronic atrial fibrillation. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD ten the patient was ready for discharge to rehab. The patient was discharged in good condition with appropriate follow up instructions to [Hospital3 4103] on the [Hospital ] Rehab. Medications on Admission: ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 HFA(s) inhaled every 4-6 hours AMIODARONE - 200 mg Tablet - 1 Tablet(s) by mouth once a day Take 2 tablets twice daily for 2 days only, then decrease to one tablet daily DIGOXIN - 125 mcg Tablet - one Tablet(s) by mouth every other day INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 20 Solution(s) at bedtime INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - Dosage uncertain METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth DAILY (Daily) OXYCODONE-ACETAMINOPHEN - (Prescribed by Other Provider: [Name Initial (NameIs) ]) - 5 mg-325 mg Tablet - 1 Tablet(s) by mouth every six (6) hours as needed for pain has narcotics contract POTASSIUM CHLORIDE - 20 mEq Tablet, ER Particles/Crystals - 1 Tablet(s) by mouth once a day SILDENAFIL [REVATIO] - 20 mg Tablet - 2 Tablet(s) by mouth three times a day SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth once a day TORSEMIDE - 20 mg Tablet - 4 Tablet(s) by mouth DAILY (Daily) WARFARIN - 5 mg Tablet - daily [Name8 (MD) ] MD*Last dose=[2182-8-22] 5mg ZOLPIDEM - 5 mg Tablet - 1 Tablet(s) by mouth at bedtime - No Substitution ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day - No Substitution CAMPHOR-MENTHOL [SARNA ANTI-ITCH] - (Prescribed by Other Provider) - 0.5 %-0.5 % Lotion - 1 Lotion(s) four times a day as needed for pruritis Plavix - last dose:Coumadin last dose 8/18/11-5mg Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 3. sildenafil 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. torsemide 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 6. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. nitrofurantoin macrocrystal 50 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 1 days: for UTI. 9. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO ONCE (Once) for 1 doses: titrate dose for goal INR of [2-7] for atrial fibrillation. next INR check on [9-13*]. Tablet(s) 10. hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s)* Refills:0 Discharge Disposition: Extended Care Facility: tbd Discharge Diagnosis: Diabetes, Dyslipidemia,Hypertension, Afib s/p failed cardioversion (coumadin), Dilated cardiomyopathy, non-ischemic- CAD CHF (EF 25-35%), PFO, severe PHTN on sidafenil, CKD (Cr 1.7), CVA/ [2175](L sided facial droop-resolved), Osteoarthritis, Depression, Hodgkin's disease s/p surgical excision and CTX at age 18. Appendectomy/Hernia repair/Back surgery after 36 foot fall, Multiple operations to bilateral knees, Multiple abdominal surgeries (removal of small bowel polyps followed by surgeries to fix complications of previous surgeries), Lymph node removal Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: Recommended Follow-up: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] [Telephone/Fax (1) 170] on [10-9] at 2:15 in the [Hospital ] medical office building [Hospital Unit Name ] Cardiologist: Dr. [First Name (STitle) 437] on [9-17] at 1pm Please call to schedule appointments with your Primary Care Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 8598] in [4-9] 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:[2182-9-12]	[ "599.0", "715.90", "416.8", "424.0", "414.01", "427.31", "428.23", "V70.7", "V12.54", "250.00", "585.9", "V58.67", "311", "745.5", "041.04", "327.23", "V10.72", "V58.61", "428.0", "425.4" ]	icd9cm	[ [ [] ] ]	[ "37.21", "36.15", "39.61", "35.33", "35.71", "36.12" ]	icd9pcs	[ [ [] ] ]	12125, 12155	7821, 9595	394, 697	12763, 12977	4940, 7798	13818, 14495	4073, 4166		11122, 12102		12176, 12742		9621, 11099			13001, 13795								3359, 3697	4181, 4921				2982, 3095																				337, 356										725, 2869												3126, 3336			2891, 2962	3713, 4057
27,893	181,307	30111	Discharge summary	report	Admission Date: [2159-5-11] Discharge Date: [2159-5-16] Date of Birth: [2111-8-12] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [2159-5-11] Mini-MAZE Procedure with Ligation of Left Atrial Appendage [2159-5-11] Chest tube insertion [2159-5-13] Chest tube insertion History of Present Illness: Mr. [Known lastname 71780] is a 47 year old male with history of atrial fibrillation. He underwent cardioversion approximately 6 months prior with concomitant treatment with Sotalol. Since that time, he has re-developed atrial fibrillation(chronically) with associated symptoms of dyspnea on exertion and decreased exercise tolerance. A prior echocardiogram from [2159-1-18] showed only mild mitral regurgitation with trace tricuspid regurgitation and no aortic insufficiency. There was evidence of left atrial enlargement and his LVEF was estimated at 60-65%. Based upon the above, he was referred for surgical intervention. Prior to MAZE procedure, he underwent cardiac MRI for pulmonary vein isolation/mapping. Past Medical History: Atrial Fibrillation - s/p Cardioversion Hypertension Hypercholesterolemia Diabetes Mellitus Type II Right Shoulder Surgery Social History: Quit smoking in [2149], but admits to 30-50 pack year history of tobacco. He denies ETOH. Married, lives in [Hospital1 10478]. Employed as a dental [Hospital1 ] tech. Family History: Strong family history of diabetes. Denies premature CAD. Physical Exam: Pre Admit Vitals: BP 112/62, HR 86, RR 12 General: well developed male in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, no carotid bruits Heart: irregular 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: nonfocal Discharge Vitals: BP 100/62, HR 68, RR 18 wt 107.9 General: well developed male in no acute distress Heart: RRR, normal s1s2, no murmur or rub Lungs: clear bilaterally, sq emphysema in left chest into neck and small amt mid chest Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, trace edema Neuro: nonfocal, a/o x3 Incision L/R mini thoracotomy healing no drainage/erythema Old CT sites with occlusive dressing Pertinent Results: [2159-5-16] 06:40AM BLOOD WBC-4.6 RBC-3.92* Hgb-12.3* Hct-36.2* MCV-92 MCH-31.4 MCHC-34.0 RDW-14.2 Plt Ct-273 [2159-5-11] 09:01AM BLOOD WBC-3.9* RBC-4.02* Hgb-12.5* Hct-37.2* MCV-93 MCH-31.0 MCHC-33.5 RDW-13.8 Plt Ct-239 [2159-5-16] 06:40AM BLOOD Plt Ct-273 [2159-5-16] 06:40AM BLOOD PT-11.7 INR(PT)-1.0 [2159-5-11] 06:45AM BLOOD PT-11.6 PTT-20.5* INR(PT)-1.0 [2159-5-16] 06:40AM BLOOD UreaN-15 Creat-1.1 K-4.4 [2159-5-15] 06:55AM BLOOD Glucose-84 UreaN-21* Creat-1.0 Na-139 K-4.0 Cl-102 HCO3-29 AnGap-12 [2159-5-11] 02:12PM BLOOD UreaN-17 Creat-1.2 Cl-104 HCO3-25 RADIOLOGY Final Report CHEST (PA & LAT) [2159-5-15] 8:53 AM CHEST (PA & LAT) Reason: re-eval bilat ptx [Hospital 93] MEDICAL CONDITION: 47 year old man with PAF s/p Mini MAZE REASON FOR THIS EXAMINATION: re-eval bilat ptx HISTORY: 47-year-old man with paroxysmal atrial fibrillation status post mini maze procedure. COMPARISON: [2159-5-14]. CHEST, PA AND LATERAL: Cardiac, mediastinal, and hilar contours are stable. Pulmonary vasculature is unremarkable. Small opacities in the left lung fields near the chest tubes are unchanged. Tiny apical pneumothoraces are unchanged. Bilateral chest tubes are in stable position. The degree of subcutaneous emphysema has slightly decreased on the right. IMPRESSION: Stable radiographic appearance of the chest with tiny apical pneumothoraces. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) 5004] THAM DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 21884] Approved: TUE [2159-5-15] 7:27 PM Cardiology Report ECHO Study Date of [2159-5-11] PATIENT/TEST INFORMATION: Indication: Maze ablation Status: Inpatient Date/Time: [2159-5-11] at 10:37 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW-1: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name8 (NamePattern2) 177] [Last Name (NamePattern1) ] MEASUREMENTS: Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.6 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 50% to 55% (nl >=55%) Aorta - Ascending: 2.4 cm (nl <= 3.4 cm) INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thicknesses and cavity size. LV WALL MOTION: basal anterior - normal; mid anterior - normal; basal anteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal; mid inferoseptal - normal; basal inferior - normal; mid inferior - normal; basal inferolateral - normal; mid inferolateral - normal; basal anterolateral - normal; mid anterolateral - normal; anterior apex - normal; septal apex - normal; inferior apex - normal; lateral apex - normal; apex - normal; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. The patient was under general anesthesia throughout the procedure. Conclusions: No spontaneous echo contrast is seen in the left atrial appendage. Left ventricular wall thicknesses and cavity size are normal. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. LAA shown to have been ligated. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3318], MD on [2159-5-11] 13:29. [Location (un) ] PHYSICIAN Cardiology Report ECG Study Date of [2159-5-11] 3:38:46 PM Sinus rhythm. Low QRS voltage. Diffuse non-diagnostic repolarization abnormalities. Compared to previous tracing of [2159-5-4] cardiac rhythm now sinus mechanism. Read by: [Last Name (LF) ],[First Name4 (NamePattern1) ] [Last Name (NamePattern1) 975] Intervals Axes Rate PR QRS QT/QTc P QRS T 75 172 108 384/412.57 72 76 71 Brief Hospital Course: Mr. [Known lastname 71780] was admitted and underwent mini-MAZE procedure with ligation of left atrial appendage. For surgical details, please see separate dictated operative note. Following the operation, he was brought to the CSRU for invasive monitoring. He had additional chest tube inserted for pneumothorax with subcutaneous emphysema on the left side without difficulty. Within 24 hours, he awoke neurologically intact and was extubated without incident. Postoperatively, he was in a normal sinus rhythm and was maintained on Amiodarone. Routine chest x-rays were notable for a persistent left apical pneumothorax and continued with subcutaneous emphysema. Serial chest x-rays were performed. Due to persistent pneumothorax and gradual worsening of subcutaneous emphysema, a third left sided chest tube was placed. He otherwise maintained stable hemodynamics with satisfactory oxygen saturations, and transferred to the SDU for further care recovery. He continued to progress and all chest tubes except the left apical were removed POD 4. He did well for 24 hours and last chest tube was removed on POD 5. He was ready for discharge home with plan for follow up chest xray and wound check on [Hospital Ward Name 121] 2. Plan for coumadin with results to [Hospital1 ] heart center coumadin clinic. Medications on Admission: Warfarin, Zetia 10 qd, Glyburide 2.5 [Hospital1 ], Avandia 4 [Hospital1 ], Metformin 100 [Hospital1 ], Toprol XL 50 qd, Tricor 145 qd Discharge Medications: 1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 3. Avandia 4 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 4. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:0 5. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. Disp:45 Tablet Sustained Release 24 hr(s) Refills:0 6. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) for 6 weeks. Disp:360 Tablet(s) Refills:0 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): take two tablets twice a day until [5-17] then decrease to 2 tablets once daily for 7 days then decrease to one tablet once a day and follow up with Dr [Last Name (STitle) ] . Disp:120 Tablet(s) Refills:0 8. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO QD (). Disp:30 Tablet(s) Refills:0 9. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3H as needed. Disp:60 Tablet(s) Refills:0 10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 13. Outpatient [Name (NI) ] Work PT/INR as needed coumadin dosing - indication atrial fibrillation s/p MAZE goal INR 2.0-2.5 with results to coumadin clinic [Hospital1 ] heart center #([Telephone/Fax (1) 20259] first draw [2159-5-18] 14. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: please take 3mg [5-16] and [5-17] with [Month/Year (2) ] draw [5-18] for further dosing . Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 ] VNA, [Hospital1 1559] Discharge Diagnosis: Atrial Fibrillation - s/p MAZE procedure Postoperative Pneumothorax Subcutaneous emphysema History of Cardioversion Hypertension Hypercholesterolemia Diabetes Mellitus Type II Right Shoulder Surgery Discharge Condition: Good Discharge Instructions: Dressing on chest tube site to remained sealed until [5-18] pm then remove and leave open to air Shortness of breath or difficulty breathing please seek emergency assistance Patient should shower daily after [5-18] when Chest ube dressing removed, no baths or swimming. No creams, lotions or ointments to incisions. No driving while taking pain medication and until seen by cardiologist No lifting more than 10 lbs for at least 4 weeks from the date of surgery. Monitor wounds for signs of infection, redness, drainage, swelling. Please call cardiac surgeon if start to experience fevers, sternal drainage and/or wound erythema. [Telephone/Fax (1) 170] Followup Instructions: Dr. [Last Name (STitle) 914] in [2-22] weeks, call for appt [Telephone/Fax (1) 170] Dr. [Last Name (STitle) ] in [12-23] weeks, call for appt [Telephone/Fax (1) 71781] Dr. [Last Name (STitle) 20222] in [12-23] weeks, call for appt Follow up Chest Xray [5-21] please go to clinical center [Location (un) 9158] for xray then to [Hospital Ward Name ] 2 for wound check [Telephone/Fax (1) 3633] Labs: PT/INR for coumadin dosing - indication atrial fibrillation s/p MAZE goal INR 2.0-2.5 with results to coumadin clinic [Hospital1 ] heart center # ([Telephone/Fax (1) 20259] first draw [2159-5-18] Completed by:[2159-5-24]	[ "401.9", "512.1", "427.31", "998.81", "272.0", "250.00", "E878.8" ]	icd9cm	[ [ [] ] ]	[ "37.33", "34.04" ]	icd9pcs	[ [ [] ] ]	10980, 11053	7441, 8761	340, 491	11296, 11303	2480, 3191	12016, 12702	1601, 1659		8957, 10957	3228, 3267	11074, 11275		8787, 8934			11327, 11993					4184, 7418				1674, 2461																								281, 302	3296, 4158									519, 1242															1264, 1389	1405, 1585
41,287	158,078	4142+55546	Discharge summary	report+addendum	Admission Date: [2175-1-17] Discharge Date: [2175-2-7] Date of Birth: [2101-9-11] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: left heart catheterization, coronary angiogram ([2175-1-17]) coronary artery bypass grafts x4 (LIMA to LAD, SVG to DIAG, SVG to OM, SVG to PDA), intraaortic balloon pump- [1-24] History of Present Illness: This 73 year-old female with insulin dependent diabetes and inferior MI in [2162] presented with chest pain, jaw pain and diaphoresis the morning of admission. . This lasted about 30 minutes and resolved with a SL NTG. She visited Dr. [Last Name (STitle) 1007], her PCP, [Name10 (NameIs) ] was sent to the ED. Of note, her presentation during her IMI 12 years ago was similar. Per review of chart, she does have occasional lower chest/epigastric pain which is relieved by SL NTG or TUMS; this has been thought not to be consistent with angina. In the ED, T was 97.6, BP 144/(no diastolic recorded), HR 72, RR 20, 100% RA. She was pain-free but did complain of malaise and mild nausea. By report, EKG was concerning for isolated ST elevation in lead III. Labs were significant for hematocrit 35.6, creatinine 1.5 (baseline ), Troponin of 0.60. She was taken directly to cardiac catherization and found to have three vessel disease with LMCA 70%, mid-LAD 90%, proximal LCx 90%, mid-RCA 90%, distal RCA 90% stenoses. No stents were placed and patient was referred for CABG. Past Medical History: Coronary artery disease s/p inferior MI in [2162] (mid and distal RCA stents placed) insulin dependent diabetes mellitus(followed by [Last Name (un) ]- last A1c 7.5.) degenerative joint disease obesity hypertension Social History: Retired bank manager. Lives with her husband. Smoked 2PPD x20 years, quit 30 years ago. Occasional alcohol use. Denies illicit drug use. Family History: Several family members with MI at early age - mother in 50s, brother in 40s, and sister in 60s. Physical Exam: Admission: 141/59, 89, 16, 95% RA Gen: Resting comfortably, NAD. In supine position, post-cath. HEENT: NCAT. Sclera anicteric. Neck: Unable to assess for JVD due to body habitus. CV: Distant heart sounds, RRR, normal S1/S2. No murmurs appreciated. Chest: Limited by anterior auscultation. No wheezes, rales, rhonchi appreciated. Normal work of breathing. Abd: Obese, soft, nontender, not distended. Ext: Trace lower extremity edema. Radial pulses 2+ bilaterally, DP pulses 1+ bilaterally. Skin: Varicose veins, R>L Neuro: CNII-XII intact. Upper and lower extremity sensation intact. Pertinent Results: PRE-BYPASS: 1. The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is severe regional left ventricular systolic dysfunction with inferior, septal and apical hypokinesis. Overall left ventricular systolic function is severely depressed (LVEF= 25-30 %). 3. Right ventricular chamber size and free wall motion are normal. 4. There are complex (>4mm) atheroma in the aortic arch. There are complex (mobile) atheroma in the descending aorta. 5. There are three aortic valve leaflets. There is no aortic valve stenosis. No aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Moderate Central (2+) mitral regurgitation is seen at a BP of 90/45 mm of Hg that worsened to 3+ at a BP 130-140/70-80. 7. There is a trivial/physiologic pericardial effusion. POST-BYPASS1: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine, Epinephrine, Norepinephrine, Milrinone and Vasopressin. Pt was being AV paced 1. MR is severe, RV function is mild-moderately depressed, LV function appears unchanged. POST-BYPASS2:For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine, Epinephrine, Norepinephrine, Milrinone. Pt was in sinus tachycardia with frequent APCs. 1. MR was initially trace but worsened to moderate - severe, RV function is hyperdynamic, LV function is worse with anterior wall motion abnormalities POST-BYPASS3: For the post-bypass study, the patient was receiving vasoactive infusions including Norepinephrine, Milrinone and Vasopressin. 1. MR is trace. 2. An IABP is present in the descending thoracic aorta with its end terminating 3 cm below the left subclavian take off 3. LV function is significanly improved. 4. RV is still hyperdynamic. 5. Aorta is intact post decannulation. 6. Inter atrial septum is dynamic Electronically signed by [Name6 (MD) 928] [Name8 (MD) 929], MD, MD, Interpreting physician [Last Name (NamePattern4) ] [2175-1-24] 14:21 [2175-2-6] 01:52AM BLOOD WBC-8.9 RBC-2.97* Hgb-9.6* Hct-27.9* MCV-94 MCH-32.4* MCHC-34.6 RDW-17.8* Plt Ct-289 [2175-2-7] 06:05AM BLOOD PT-31.4* INR(PT)-3.2* [2175-2-6] 01:52AM BLOOD PT-31.1* PTT-35.8* INR(PT)-3.2* [2175-2-5] 01:54AM BLOOD PT-29.0* PTT-35.0 INR(PT)-2.9* [2175-2-4] 09:30AM BLOOD PT-24.9* INR(PT)-2.4* [2175-2-3] 03:40AM BLOOD PT-19.0* PTT-57.4* INR(PT)-1.8* [2175-2-6] 01:52AM BLOOD UreaN-34* Creat-1.0 Na-140 Cl-109* HCO3-24 Brief Hospital Course: Following admission she underwent catheterization which revealed triple vessel disease. She was referred for surgical intervention. After 7 day of Plavix washout, she underwent CABG x4 with Dr. [First Name (STitle) ]. She weaned from bypass on Milrinone, vasopressin,Levophed and Propofol. An IABP was necessary as well. She stabilized, the balloon pump was removed on POD 1 and pressors were weaned over a couple of days. Diuresis was begun, she remained stable from a cardiovascular standpoint but required extensive pulmonary toilet and diuresis. A CT was placed for a large pleural effusion and she was able to be extubated on POD 8. She had recurrent atrial fibrillation, despite amiodarone and attempts at cardioversion, and Coumadin was begun. She did convert to sinus rhythm eventually. Beta blockers were begun, however, they were discontinued on [2-7] for bradycardia, the rhythm remaining sinus. Coumadin was continued due to the postoperative atrial fibrillation. her target INR is 2-2.5. She stabilized and with vigorous diuresis and pulmonary toilet progressed slowly. She was neurologically intact. Physical therapy worked with her for strength and mobilization. She was transferred to a rebabilitation facility for further recovery prior to eventual return to home. Medications on Admission: AMLODIPINE 2.5 mg PO daily NOVOLOG 12 units daily at night INSULIN DETEMIR [LEVEMIR] 80 units twice a day LIDOCAINE 5% (700 mg/patch) LISINOPRIL-HYDROCHLOROTHIAZIDE 20mg/25mg PO daily NITROGLYCERIN 0.4 mg Tablet Sublingual 1 Tablet sublingually daily as needed for chest discomfort PERCOCET 5mg/325mg 1 Tablet by mouth daily ROSUVASTATIN 5mg PO daily TRIAMCINOLONE ACETONIDE 0.1% apply twice a day as needed for rash ASPIRIN 325mg PO daily CALCIUM-CHOLECALCIFEROL 600mg-400 unit PO daily MVI Discharge Medications: 1. Influen Tr-Split [2173] Vac (PF) 45 mcg/0.5 mL Syringe Sig: One (1) ML Intramuscular ASDIR (AS DIRECTED) for 1 doses. 2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [12-9] Drops Ophthalmic PRN (as needed). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Tobramycin Sulfate 0.3 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day) for 3 days. 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for 2 weeks. 8. Warfarin 1 mg Tablet Sig: daily order Tablet PO once a day: INR target 2-2.5. 9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). 12. Coumadin 1 mg Tablet Sig: daily order Tablet PO once a day: no coumadin [2-7]. 13. Insulin Glargine 100 unit/mL Cartridge Sig: Eighty (80) units Subcutaneous once a day. 14. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: see sliding scale Subcutaneous see sliding scale: ac coverage: 120-160: 2u sc 161-200: 4u sc 201-240: 6u sc 241-280: 8u sc 281-300: 10u sc. Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 533] [Last Name (NamePattern1) ] for Extended Care - [Location 1268] Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass grafts s/p coronary angioplasty and stent insulin dependent Diabetes mellitus Hypertension obesity degenerative joint disease neuropathy obesity degenerative joint disease and chronic back pain Discharge Condition: good Discharge Instructions: no lotions, creams or powders on any incision shower daily and pat incisions dry no driving for one month and off all narcotics no lifting greater than 10 pounds for 10 weeks call for fever greater than 100.5 call for redness of ,or drainage from incisions Call for weight gain of 2 pounds in 2 days or 5 pounds in a week take all medications as directed Followup Instructions: see Dr. [Last Name (STitle) 1007] in [12-9] weeks ([Telephone/Fax (1) 10492]) see Dr. [Last Name (STitle) ] in [1-10] weeks see Dr. [First Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] please call for all appointment. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2175-2-7] Name: [Known lastname 2913],[Known firstname 1194] Unit No: [Numeric Identifier 2914] Admission Date: [2175-1-17] Discharge Date: [2175-2-7] Date of Birth: [2101-9-11] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 265] Addendum: Dr. [Last Name (STitle) 85] informs me that the patient did not in fact see him in the office the day she was admitted as the medical admission note stated. Chief Complaint: angina Major Surgical or Invasive Procedure: left heart catheterization, coronary angiogram ([2175-1-17]) coronary artery bypass grafts x4 (LIMA to LAD, SVG to DIAG, SVG to OM, SVG to PDA), intraaortic balloon pump- [1-24] History of Present Illness: see d/c summary Past Medical History: Coronary artery disease s/p inferior MI in [2162] (mid and distal RCA stents placed) insulin dependent diabetes mellitus(followed by [Last Name (un) 616]- last A1c 7.5.) degenerative joint disease obesity hypertension Social History: Retired bank manager. Lives with her husband. Smoked 2PPD x20 years, quit 30 years ago. Occasional alcohol use. Denies illicit drug use. Family History: Several family members with MI at early age - mother in 50s, brother in 40s, and sister in 60s. Physical Exam: see d/c summary Pertinent Results: see prior summary Brief Hospital Course: see summary done [2175-2-7] Medications on Admission: see summary Discharge Medications: 1. Influen Tr-Split [2173] Vac (PF) 45 mcg/0.5 mL Syringe Sig: One (1) ML Intramuscular ASDIR (AS DIRECTED) for 1 doses. 2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [12-9] Drops Ophthalmic PRN (as needed). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Tobramycin Sulfate 0.3 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day) for 3 days. 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for 2 weeks. 8. Warfarin 1 mg Tablet Sig: daily order Tablet PO once a day: INR target 2-2.5. 9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). 12. Coumadin 1 mg Tablet Sig: daily order Tablet PO once a day: no coumadin [2-7]. 13. Insulin Glargine 100 unit/mL Cartridge Sig: Eighty (80) units Subcutaneous once a day. 14. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: see sliding scale Subcutaneous see sliding scale: ac coverage: 120-160: 2u sc 161-200: 4u sc 201-240: 6u sc 241-280: 8u sc 281-300: 10u sc. Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 204] [Last Name (NamePattern1) ] for Extended Care - [Location 205] Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass grafts s/p coronary angioplasty and stent insulin dependent Diabetes mellitus Hypertension obesity degenerative joint disease neuropathy obesity degenerative joint disease and chronic back pain Discharge Condition: good Discharge Instructions: no lotions, creams or powders on any incision shower daily and pat incisions dry no driving for one month and off all narcotics no lifting greater than 10 pounds for 10 weeks call for fever greater than 100.5 call for redness of ,or drainagefrom incisions Call for weight gain of 2 pounds in 2 days or 5 pounds in a week take all medications as directed Followup Instructions: see Dr. [Last Name (STitle) 85] in [12-9] weeks ([Telephone/Fax (1) 2915]) see Dr. [Last Name (STitle) 1426] in [1-10] weeks see Dr. [First Name (STitle) ] in 4 weeks [Telephone/Fax (1) 1477] please call for all appointment. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 266] Completed by:[2175-2-7]	[ "721.90", "362.01", "707.22", "414.01", "V58.67", "707.05", "486", "427.31", "E878.2", "401.9", "427.32", "250.50", "412", "250.60", "278.00", "785.51", "V45.82", "287.4", "428.0", "276.4", "715.90", "458.29", "997.1", "997.31", "428.23", "518.5", "410.71", "278.01", "707.03", "357.2" ]	icd9cm	[ [ [] ] ]	[ "37.61", "36.13", "99.61", "33.24", "37.22", "36.15", "88.56", "38.93", "96.72", "96.6", "97.44" ]	icd9pcs	[ [ [] ] ]	12903, 13037	11353, 11386	10510, 10698	13326, 13333	11311, 11330	13736, 14110	11163, 11260		11448, 12880		13058, 13305		11412, 11425			13357, 13713									11275, 11292																								10464, 10472										10726, 10743															10765, 10992	11008, 11147
75,223	174,855	23247	Discharge summary	report	Admission Date: [2113-9-26] Discharge Date: [2113-9-28] Date of Birth: [2050-4-17] Sex: M Service: MEDICINE Allergies: Ciprofloxacin Attending:[First Name3 (LF) 2387] Chief Complaint: s/p carotid stenting Major Surgical or Invasive Procedure: carotid stenting of right carotid artery History of Present Illness: 63 yo male with history of HTN, HL, and claudication who is s/p carotid stenting for 90% stenosis on right admitted for monitoring. . Approximately 3 months ago, he had a stress echo (nl, EF >50%, negative for ischemia), and at that time, a carotid bruit was heard. Carotid US and CT neck with contrast were done (results not available on admission). Per patient, he had 90% stenosis on right and 50-60% stenosis on left. He has been asymptomic and scheduled an elective surgery today. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis. he denies recent fevers, chills or rigors. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: cardiac catheterization - [2111-3-26]: 30% mid plaque lesion in the LAD at the diagnoals and only minimal disease in the other vessels 3. OTHER PAST MEDICAL HISTORY: Hyperlipidemia GERD claudication s/p left SFA stent distant h/o gastric ulcer hydrocele s/p indigo laser procedure tobacco abuse adenocarcinoma of the rectosigmoid [Month/Day/Year 499] s/p surgery BPH Social History: Currently smokes tobacco since age 15 at least 1ppd (45pack-year), now smokes approximately 0.5-1 ppd. He drinks 1 alcoholic drinks per week. Married and works as engineer. Family History: His family history is significant for a mother with MI in her 50s and pacemaker. Mother had [Name2 (NI) 499] cancer and DM too. Not in touch with father Physical Exam: GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: Sclera anicteric. EOMI. no oral lesions. NECK: Supple, bruit on left CARDIAC: RRR LUNGS: CTAB ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: no pedal edema, distal pulses intact, right groin nontender, without brusing or bruits SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Neuro: CN II-XII intact, nl strength and sensation in upper and lower extremities bilaterally, nl rapid alternating movements of hands Pertinent Results: [2113-9-26] 07:55AM BLOOD WBC-7.1 RBC-4.36* Hgb-12.5* Hct-36.4* MCV-84 MCH-28.8 MCHC-34.5 RDW-15.0 Plt Ct-269 [2113-9-27] 05:24AM BLOOD WBC-9.1 RBC-4.05* Hgb-11.4* Hct-34.3* MCV-85 MCH-28.2 MCHC-33.3 RDW-15.0 Plt Ct-300 [2113-9-26] 07:55AM BLOOD Glucose-101* UreaN-10 Creat-0.9 Na-140 K-4.5 Cl-104 HCO3-27 AnGap-14 [2113-9-27] 05:24AM BLOOD Glucose-104* UreaN-17 Creat-1.0 Na-140 K-4.3 Cl-105 HCO3-26 AnGap-13 [2113-9-27] 05:24AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.1 Brief Hospital Course: 63 yo male with history of HTN, HL, and claudication who presents after carotid stenting for monitoring. # Carotid stenting - The patient tolerated the procedure well. Post procedure, the patient was hypotensive and bradycardic to the 40s. He was started on dopamine and transferred to the CCU for monitoring. The dopamine drip was able to be weaned after one night and the patient's blood pressure rose to 120s without any medication. He ambulated around the unit without difficulty and tolerated PO intake well. He was started on a full dose aspirin. Plavix and statin were continued. Lisinopril and amlodipine were held due to hypotension. # Smoking cessation - The patient said he was trying to cut back his smoking habit. He was counseled that smoking cessation would be the best thing to do to lower his stroke risk. Medications on Admission: AMLODIPINE [NORVASC] - 5 mg Tablet - daily DICYCLOMINE -10 mg Capsule - 1 Capsule(s) by mouth three times a day DIPHENOXYLATE-ATROPINE - 2.5 mg-0.025 mg Tablet as needed DUTASTERIDE [AVODART] - 0.5 mg - 1 Capsule(s) by mouth qpm LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth twice a day PANTOPRAZOLE - 40 mg Tablet, - 1 Tablet(s) by mouth every afternoon PROCHLORPERAZINE MALEATE -10 mg-every 6 hours as needed for nausea ROSUVASTATIN [CRESTOR] -10 mg by mouth afternoon ASPIRIN - 81 mg Tablet - qam plavix 75 daily - started recently Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for s/p R carotid artery stent. 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for s/p R carotid artery stent. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Dicyclomine 10 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for diarrhea. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 7. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO qpm (). Discharge Disposition: Home Discharge Diagnosis: s/p carotid stenting Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 59744], It was a pleasure taking care of you during your hospitalization. You were admitted for carotid stenting of the right carotid artery. After the procedure, your heart rate and blood pressure were low. You were treated with IV dopamine, a medication that raises blood pressure and heart rate. We were able to wean the dopamine and your blood pressure and heart rate stayed stable. Please make the following changes to your medications: INCREASE aspirin to 325 mg daily Please follow-up with your scheduled appointments. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ]: [Last Name (LF) 766], [10-2] at 3:45. You can reach the office at ([Telephone/Fax (1) 32215]. Provider: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2113-11-23] 3:40. They will try go get you sooner and call you. You are in the urgent waiting list.	[ "V70.7", "305.1", "458.29", "427.89", "272.4", "401.9", "443.9", "V16.0", "531.90", "600.00", "V10.60", "530.81", "433.10", "603.8" ]	icd9cm	[ [ [] ] ]	[ "00.40", "00.45", "00.61", "00.63", "36.06" ]	icd9pcs	[ [ [] ] ]	5496, 5502	3190, 4023	295, 338	5567, 5567	2682, 3167	6303, 6729	1990, 2149		4616, 5473		5523, 5546		4049, 4593			5718, 6165									2164, 2663				1408, 1547														6194, 6280						235, 257										366, 1314											5582, 5694	1578, 1784			1336, 1388	1800, 1974
11,207	101,078	4712	Discharge summary	report	Admission Date: [2107-3-12] Discharge Date: [2107-3-18] Date of Birth: [2030-1-25] Sex: F Service: NSU HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old woman status post bilateral nephrectomy and on hemodialysis, status post a DVT with IVC filter placement, who was at [Hospital3 7] recuperating from her nephrectomy surgery, and over the past week had developed mild left upper extremity weakness. Workup included a MRI scan at [Hospital3 9717] which showed a right subdural hematoma in the right cerebral hemisphere and right frontal subdural hygroma. The patient was transferred to [Hospital1 188] for further management. PAST MEDICAL HISTORY: Right nephrectomy in [2106], left nephrectomy in [2093], status post DVT with SVC filter placement, she is HIT positive, breast cancer, MI in [2106], hepatitis A and B. PHYSICAL EXAMINATION ON ADMISSION: Her temperature is 98.1, heart rate is 89, BP is 157/72, respiratory rate is 18, saturation is 96% on room air. Awake, alert, and oriented x 3 with no facial droop. Pupils are equal, round and reactive to light and accommodation. EOMs are full. Cardiovascular with a regular rate and rhythm. Chest is clear to auscultation bilaterally. The abdomen is soft, nontender, and nondistended. Positive bowel sounds. Extremities reveal no edema. Muscle strength is [4-21] except for the left upper extremity which is [3-22]. HOSPITAL COURSE: The patient was admitted to the ICU for close neurologic observation. The renal service was consulted due to her need for hemodialysis. The patient was evaluated by the neurosurgical service and felt to require bur hole drainage of the subdural hematoma. The patient was seen by Dr. [Last Name (STitle) 1327] and prepared for surgery. On [2107-3-14] the patient underwent a right frontal parietal craniotomy bur hole drainage of a subdural hematoma without intraoperative complication. Postoperatively, the patient had no complaints of headache. She reported improved dexterity in the left hand. Vital signs were stable, and her strength was [4-21] in all muscle groups. She had no drift. Her face was symmetric. Her dressing was clean, dry, and intact. She was transferred to the regular floor on postoperative day 1. Her subdural drain was removed. She had a repeat head CT which showed good evacuation of the subdural. She continued to be followed by the renal service and undergo every other day renal dialysis. She was evaluated by the physical therapy and occupational therapy service and felt to be safe for discharge to home with home PT and OT. Her condition was stable, and a repeat head CT prior to discharge showed a stable condition of the evacuation of her subdural hematoma. DISCHARGE FOLLOWUP: She was discharged on [2107-3-18] with followup for staple removal on Monday, [2-18], at 10:00 a.m. and followup with Dr. [First Name (STitle) ] in 1 month for a repeat head CT. MEDICATIONS ON DISCHARGE: 1. Famotidine 20 mg p.o. b.i.d. 2. Percocet 1 to 2 tablets p.o. q.4h. p.r.n. 3. Metronidazole 500 mg p.o. q.12h. (for 5 days - to finish up a course for C. difficile). 4. Dilantin 100 mg p.o. t.i.d. CONDITION ON DISCHARGE: The patient's condition was stable at the time of discharge. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 8632] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2107-3-18] 15:21:00 T: [2107-3-18] 16:26:20 Job#: [Job Number 19846]	[ "432.1", "V10.53", "428.0", "410.72", "438.31", "V10.3", "V45.73", "403.91" ]	icd9cm	[ [ [] ] ]	[ "01.31", "99.07", "39.95" ]	icd9pcs	[ [ [] ] ]												3007, 3211		1465, 2769																																					2790, 2981								165, 680									921, 1447						703, 906		3236, 3561
31,315	158,724	31439	Discharge summary	report	Admission Date: [2106-6-30] Discharge Date: [2106-7-22] Date of Birth: [2065-8-27] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1666] Chief Complaint: transfer for management of intracranial masses; also, odynophagia and hematemesis Major Surgical or Invasive Procedure: Brain Bx Lumbar Puncture Bone Marrow Bx EGD#1 EGD#2 History of Present Illness: 40yo M with AIDS (CD4 9, VL>500,000) presents for admission and ID consult to manage known CNS lesions. He was diagnosed with AIDS on [2106-5-18] and found to have multiple CNS lesions. He was admitted to [Hospital3 ] [2106-6-10] - [2106-6-24] and CNS lesions were treated as toxo empirically. He also received dexamethasone for cerebral edema. However, repeat head CT on [2106-6-28] failed to show resolution of the lesions, so he was transferred to [Hospital1 18] for further management. . In terms of his HIV, he was diagnosed on [2106-5-18] when he was hospitalzed for cough and interstitial infiltrates on CXR. On CT scan, there were diffuse ground glass opacities and infection was presumed, although no micro dx was made (AFB smears negative, legionella/mycoplasma negative). HIV RNA returned >500k, CD4 of 9. On [6-10], he was admitted to OSH for weakness, fever, confusion, and vomiting. Head CT revealed 1 cm lesion in the R thalamus and 2x2 cm lesion in R parietal lobe (no ring enhancement). He was unable to get an MRI because of residual shrapnel. Toxo serologies were +, crypto Ag was negative. He was empirically tx'd for toxo w/ pyrimethamine, sulfadiazine and decadron 4 mg qid, tapered to 3mg qid. He was discharged on [6-24] and advised to f/u with Dr. [Last Name (STitle) ] in ID who continued empiric tx for toxoplasmosis and started him on fluconazole for thrush. A f/u head CT scan [6-27] revealed only slight improvement in R parietal ahd thalamic lesions, so he was referred to [Hospital1 18] for a 2nd opinion and further imaging and/or brain biopsy. Dr. [Last Name (STitle) 74037] received the referral at [Hospital1 18]. Past Medical History: # appendectomy # gun shot wounds in a robbery, w/ shrapnel in neck and L chest Social History: Wife and 3 children live in [Country 4194] and are unaware of his diagnosis. Currently lives with brother in [Name (NI) 3494], works in junkyard. No EtOH, h/o tobacco use. Denies IVDU, rec drug use. Family History: 12 siblings, 2 brothers in US - all healthy per report F 82 good health M died at 58 of liver cancer Physical Exam: VS: T 99.6, BP 91/49, HR 58, RR 16, sats 100% on RA GEN: WDWN middle aged male in NAD. HEENT: L pupil more sluggish than right, but both pupils are reactive. EOMI, no nystagmus. Sclera anicteric. OP with thick thrush all over tongue. MMM. No LAD appreciated. CV: RR, normal S1, S2. No m/r/g. PULM: CTAB, no c/r/w. ABD: Soft, mildly distended, NT, + BS, no HSM. EXT: Warm, 2+ DP/radial pulses BL, no edema. NEURO: CN II-XII grossly intact. [3-25] dorsiflexion on L, [4-24] dorsiflexion on R; symmetric [4-24] on plantarflexion bilaterally. Knee flexion/extension [3-25] on L, [4-24] on R. Hip flexion [4-24] on R, [3-25] on L. Biceps/triceps [3-25] on L, [4-24] on R. Grip weaker on L. Sensation to LT appears intact in UE and LE bilaterally. SKIN: 2 blackened lesions on right underside of his lower lip, nonbleeding. No rash, but has large ecchymotic area on abdomen (at site of appy scar). Also with small scattered hyperpigmented, flat macular lesions across lower aspect of his abdomen, R>L. Pertinent Results: [2106-7-21] CT head results per radiology: Several hypodense lesions, small R anterior SDH resolving. CBC on discharge: WBC-4.0 RBC-3.45* Hgb-10.7* Hct-30.3* MCV-88 MCH-31.2 MCHC-35.5* RDW-17.3* Plt Ct-547* note platelet nadir 27,000 on [2106-7-10] Chemistries on discharge: Glucose-88 UreaN-13 Creat-1.0 Na-136 K-3.5 Cl-97 HCO3-29 AnGap-14. [7-5] and [7-9] EGD Esophagitis, appeared consistent with candidiasis. Brief Hospital Course: This 40 year old gentleman recently diagnosed with AIDS was transferred from an outside hospital when new brain lesions were found in a workup for mental status changes. He has had a complex course during which he was discovered to have CMV viremia, [Female First Name (un) ]/HSV esophagitis leading to unstable upper GI bleed, pancytopenia, and a small SDH. The brain lesions were biopsied by neurosurgery but, unfortunately, the biopsy is non-diagnostic. Shortly thereafter he underwent a lumbar puncture which was non diagnostic. He was maintained pyrimethamine for presumed toxoplasmosis. A possible cause of his mental status change was revealed when studies found him to have CMV viremia--the patient was started on valganciclovir with some improvment in mental status. On [7-9] the patient underwent EGD for continued odynophagia--he had been on fluconzole for presumed candidiasis. The EGD revealed severe erosive candidiasis--a few days later the patient developed hematemesis/upper GI bleed with hemodynamic instability (of note pt was pancytopenic in this setting). Repeat endoscopy confirmed general bleeding from the inflammed upper GI mucosa-a biopsy revealed the presence of HSV. Per ID consult pt was switched to IV ganciclovir. The bleed resolved and pt transferred back to floor on [7-11]--pt had no further evidence of GI bleed. Shortly thereafter, pt was started on HAART per recommendation of ID service. His pancytopenia resolved and he showed no signs of immune reconstitution syndrome and by this time his mental status had normalized . Serial head CTs revealed no change in the brain lesions. There was revealed a small R sided a SDH which was resolving by time of discharge. Pt remained hemodynamically stable with good mental status at time of discharge. He is to follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], Infectious Disease special at [Hospital1 3494] Health Services. Of note, he has not revealed his diagnosis of AIDS to his family. See below for individual summary of the many issues of this pt: Neuro: Pt was admitted to the hospital for work up of CNS lesions discovered after admission to an OSH for mental status changes. He was empirically treated for toxoplasmosis, with little response. While at [Hospital1 18], a brain biopsy was performed on [7-2] which was nondiagnostic. A lumbar puncture on [7-6] also did not confirm a diagnosis. He had a thallium SPECT scan and a FDG PET CT scan, both of which ruled out CNS lymphoma. He was continued on treatment for toxoplasmosis, steroids were d/DC'ed on [7-8]. Head CT on [7-13] revealed stable CNS lesions but a new small SDH; his neuro exam through his admission was notable for improving left-sided weakness. Repeat head CT on [7-22] showed stable lesions and SDH. . GI: Patient was also complaining of pain with swallowing. He was one week into treatment with fluconazole, with no resolution of symptoms when admitted. An EGD was performed on [7-5], which demonstrated severe erosive esophagitis consistent with candidiasis. The patient was switched to Caspofungin. The biopsy was negative for [Female First Name (un) 564], positive for HSV, after which steroids were discontinued and he was started on acyclovir on [7-8]. He had had an episode of hematemesis on [7-8]. He became hypotensive with a dropping HCT, and was transferred to the ICU on [7-9]. Repeat EGD on [7-9] showed blood and clots in the esophagus and GEJ, no lesions in the stomach or duodenum. Acyclovir was discontinued when IV ganciclovir was started for CMV viremia (see below) on [7-9]. He was transferred out to the floor once hemodynamically stable and taking POs on [7-11]. His LFTs began to rise, and Caspofungin was discontinued on [7-14], with LFTs trending down at discharge. On discharge, he had much improved, mild odynophagia. . ID: HIV/AIDS - The patient had a new diagnosis of HIV prior to admission. He was started on HAART on [7-11], which he tolerated well without evidence for immune reconstitution syndrome. He was maintained on azithromycin for [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ]. CMV - The patient was found to have CMV viremia. Treatment with valganciclovir was started on [7-7]. He was switched to 2 week course of ganciclovir IV on [7-5], during which CMV viral load began to drop. He was discharged on valganciclovir 900 mg PO BID. . HEME: Over the course of his stay, the patient became pancytopenic. Bone marrow biopsy was performed on [7-9], which showed a hypocellular marrow, negative cultures, likely consistent with HIV infection vs medication side effect. His counts were trending up at discharge. . ENDO: The patient had elevated FSBS on dexamethasone, for which he was covered with ISS. FSBS were normal off steroids after [7-8]. . Social: Social work and a translator discussed the issue of disclosing his HIV status to his brother with whom he lives, and his wife in [Name (NI) 4194]. The patient does not want to disclose this information at this time. He will follow-up with social work in the office of his HIV PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. Please not summary of issues prepared by medical students [First Name4 (NamePattern1) 5045] [Last Name (NamePattern1) 74038] and [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. Medications on Admission: Pyrimethamine 75mg QD Sulfadiazine 1500mg q6hrs Leucovorin 10mg QD Dexamethasone 1.5 Q6hrs Azithromycin 1200mg weekly Fluconazole 100mg QD Discharge Medications: 1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 2. Pyrimethamine 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK ([Doctor First Name ]). 4. Sulfadiazine 500 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6 hours). 5. Leucovorin Calcium 5 mg Tablet Sig: Two (2) Tablet PO Q 24H (Every 24 Hours). 6. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lopinavir-Ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: PRIMARY: 1. HIV/AIDS 2. HSV esophagitis 3. CMV viremia 4. CNS toxoplasmosis 5. Brain lesions of unknown etiology Discharge Condition: Afebrile and hemodynamically stable. Very mild residual left-sided weakness and mild odynophagia. Discharge Instructions: room. You are not obligated to show this information sheet to anyone. You have been recently diagnosed with HIV infection. You were admitted to the hospital for treatment of masses that were seen in your brain. During your admission, you began vomiting with some blood, which after looking with a special camera were from a severe irritation in your stomach from HSV, a virus. ........ Please take all medications as directed and keep all doctors [Name5 (PTitle) 4314]. It is extremely important that you take your HIV medications exactly as prescribed, and we have set up follow-up to help you do this. If you develop any more bloody vomiting, or have dizziness, blurry vision, weakness, nausea, or develop shortness of breath, chest pain or feel ill, please call your primary care doctor or come into the emergency room. Followup Instructions: Please follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Hospital1 3494] Primary Care, located at [Street Address(2) ]., on Tuesday [7-27] at 5:30pm. Her phone number is [Telephone/Fax (1) 14315]. You will also be followed by [First Name8 (NamePattern2) 622] [Last Name (NamePattern1) ], Nurse [Last Name (Titles) ]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1672] MD, [MD Number(3) 1673]	[ "432.1", "078.5", "284.1", "130.7", "042", "348.8", "112.84" ]	icd9cm	[ [ [] ] ]	[ "01.13", "03.31", "41.91", "45.13", "45.16" ]	icd9pcs	[ [ [] ] ]	10671, 10677	4158, 9703	397, 450	10834, 10935	3702, 3813	11816, 12334	2531, 2634		9892, 10648		10698, 10813		9729, 9869			10959, 11793									2649, 3683																3987, 4135								276, 359										478, 2186															2208, 2290	2306, 2515
23,024	170,431	21991	Discharge summary	report	Admission Date: [2151-8-7] Discharge Date: [2151-9-2] Date of Birth: [2091-9-26] Sex: F Service: MEDICINE Allergies: Indocin / Pentothal / Morphine Sulfate Attending:[First Name3 (LF) 3913] Chief Complaint: Generalized fatigue, diarrhea, and low grade fever Major Surgical or Invasive Procedure: Placement of a femoral Hickman History of Present Illness: This is a 59 y/o female with relapsed AML who is Day 61 of non-myeloablative allogeneic transplant. The patient presented to [Hospital Ward Name 1826] 7 for monitoring of her daily counts. On the day of presentation the patient reports a one week history of loose stools and [2156-4-1] lower abdominal pain. She reports decrease P.O. intake secondary to having no appetite. While the patient does admit to occasionally feeling cold, she denies any chills or fevers. On the day of presentation the patient reports feeling a little SOB and requiring a wheelchair for transportation. . Of note within the past week the patient has been seen in clinic. On [2151-8-5] the she was seen Nurse [Last Name (Titles) 57569]. At the time the patient reported increased fatigue and decreased activity. The patient denied any SOB, chest pain, lightheadedness, fevers, chills, diarrhea, bruising, bleeding or rashes. She did report intermittent stomach upsets in temporal relationship to moving her bowels. Her labs were noteworthy for 28% blasts. . The patient was also seen by Dr. [Last Name (STitle) 12375] on [2151-8-6]. Dr. [Last Name (STitle) 12375] commented that the patient may be with recurrence of disease. Cyclosporine dose was rapidly tapered in an effort to try and reduce GVHD. A bone marrow biposy was and aspirate was done to assess the extent of involvement and chimerism. The plan at the time was to monitor the patient daily counts. . Onc History as per Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 22359] note: Ms. [Known lastname 57565] is a 59 yo woman who developed general malaise, SOB, fatigue, cough, and congestion in [8-1] and presented to her PCP. [Name10 (NameIs) 57566] tx c an inhaler, her PCP ordered routine lab work and found a white blood count of 100,000 and she was admitted to [Hospital ] Hospital. She was found to have circulating blasts and transferred to [Hospital1 69] for further evaluation. On admission to [Hospital1 18] on [2150-8-28], Ms. [Known lastname 57565] had a white blood count of 129,000. Differential showed 23% neutrophils, 70% lymphocytes, 44% monocytes, 2% bands, 2% metamyelocytes and 8% blasts. She had a platelet count of 37,000 and hematocrit of 26. Her peripheral smear revealed an increased number of monocytes and monoblasts with dysplastic neutrophils. She [Known lastname 1834] a bone marrow biopsy, which was consistent with acute monocytic leukemia. Cytogenetics were normal. She was initially started on Hydrea, allopurinol and hydration and then started on induction chemotherapy with high-dose daunorubicin and ARA-C on protocol E1900. With recovery of her counts, Mrs. [Known lastname 57565] was discharged and overall tolerated her induction therapy very well. Repeat bone marrow biopsy from [2150-10-7] showed trilineage hematopoiesis and 1% blasts, but no evidence of acute leukemia. Ms. [Known lastname 57565] was then randomized to receive two cycles of consolidation tx c high-dose ARA-C followed by autologous stem cell txp c Mylotarg. Ms.[Known lastname 57565] was admitted for her first cycle of consolidation with HiDAC on [2150-10-14]; this admission proceeded without complications. She then received her second cycle of consolidative therapy with high-dose ARA-C on [2150-11-16]. This consolidation was complicated by fever and neutropenia as well as increased dyspnea on exertion. CT scan of the chest showed evidence of diffuse interstitial markings, which were felt related to an infection or CHF. Ms. [Known lastname 57565] [Last Name (Titles) 1834] repeat echocardiogram, which revealed an ejection fraction of 30% to 35% with new left ventricular systolic and diastolic dysfunction. She was started on medication management with lisinopril and Toprol per cardiology. Her decreased EF was thought secondary to high dose anthracycline therapy. A repeat exercise stress test in [12/2150] revealed an improvement in her ejection fraction to 48%, which was also seen on cardiac MRI imaging with an EF of 49%. Symptomatically, Ms. [Known lastname 57565] continued to improve with less shortness of breath. The plan for autologous txp was withdrawn given her worsening CHF and the risk of further cardiac toxicity. She was withdrawn from the protocol with a plan for allo-BMT from an unrelated donor if her disease worsened. A drop in platelets in [3-2] precipitated a BM bx showing relapsed leukemia. She received a cycle of MEC chemotherapy in [4-1] and her hospitalization was complicated by gram-negative bacteremia. Fever w/u included a chest CT showing atypical left upper lobe infiltrate for which she was tx c fluconazole. A repeat CT scan of the chest did show improvement in the lesion and a more recent CT scan of the chest on Friday [2151-5-28] showed continued resolution of this presumed infection. Repeat ECHO in [5-2] showed a decreased EF (30-35%) c global hypokinesis of LV; she [Month/Day (1) 1834] RVG showing EF 50%. She continues to be dyspneac on exertion but does not c/o CHF symptoms. She presents for a non-myeloablative but immunoablative allo BMT from a matching unrelated donor. Her donor is male, CMV positive and blood type A positive. Ms. [Known lastname 57565] is CMV negative and blood type A positive. Besdies persistent fatigue, the pt. reports performing many ADLs independently and denies feves, rigors, CP, palpitations, SOB, cough, congestion, sore throat. She reports having her upper teeth extracted two weeks ago and has had no bleeding/no persistent pain after the procedure. Her PO intake is good and she denies N/V. She denies increased bleeding, epistaxis, any blood in the urine/stool. Past Medical History: 1. Gout. 2. Hypertension. 3. Status post tubal ligation. 4. AML as noted in history above. 5. History of gram-negative bacteremia. 6. S/p B/L tubal ligation Social History: Lives in [Hospital1 3597], [Location (un) 3844] and works as an assembler at [Company 2676] - she is currently on disability. She is divorced and has one son who is very supportive. She has 43 smoking pack-years but quit in [2150-8-28]. She had a few drinks of ETOH per week prior to her diagnosis, but does not drink ETOH currently. She denies illicit drug use. She has three cats at home and has others help her with changing the litter box. Family History: No known leukemia, lymphoma or other hematologic abnormalities. No known cancer, MI or congenital anomalies. Physical Exam: ROS Gen: fatigue, no fevers, no chills HEENT: no petechiae, no epistaxis, no odynophagia, no dysphagia Cardiac: EF 20-30%, h/o of cardiomyopathy [12-30] chemotx, no CP, no palpitations Pulm: SOB on the day of presentation GI: lower abdominal pain [2156-4-1]; diarrhea GU: no increased urgency, no increased frequency Heme/Onc: relapsed AML . Physical Exam VS: T 100.3, HR 100, BP 104/70, R20, O2 sat 97%RA Gen: Thin-appearing male in no acute distress lying in bed. Heart: nl rate, S1S2, II/VI SEM LUSB Lungs: CTA-b/l; no r/r/w Abdomen: +bs, no guarding, no rebound tenderness Extremities: erythematous-dermatitis like rash on dorsal aspects of hands, non-blanching; no c/c/e; +DP b/l Neuro: II-XII grossly intact, A&O x3 Pertinent Results: Admission Labs [2151-8-6] 09:20AM PLT SMR-VERY LOW PLT COUNT-34* [2151-8-6] 09:20AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-OCCASIONAL MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL [2151-8-6] 09:20AM NEUTS-33* BANDS-2 LYMPHS-28 MONOS-3 EOS-2 BASOS-2 ATYPS-1* METAS-0 MYELOS-0 BLASTS-29* [2151-8-6] 09:20AM WBC-2.2* RBC-3.09* HGB-10.6* HCT-31.0* MCV-101* MCH-34.2* MCHC-34.1 RDW-20.1* [2151-8-7] 09:20AM PLT COUNT-26* Brief Hospital Course: 1. VRE Bacteremia - The patient had intermittent fever spikes throughout her course. CXR and cultures were done, which did not isolate a source of infection. UA was done which showed 10K - 100K of VRE. ID recommended a repeat UA which did not grow anything. She continued to spike fevers and then became hypotensive with mental status changes. Blood cultures grew VRE. She was emperically started on daptomycin. However, cultures continued to be positive. After a family meeting, it was decided to make pt [Name (NI) 3225]. She expired on [2151-9-2]. . 2. Relapsed AML - On the day of presentation, the patient's WBC was 4.2. On [2151-8-11] it peaked at 56. The decision was made to treat her with hydroxyurea. Her WBC came down after. As of [2151-8-22], she is Day 10 of ME (mitoxantrone and etoposide - both medications were given at a reduced dose). The usual regimen is MEC. She did not receive cytarabine because she had a bad reaction to it in the past. . 3. Diarrhea - Patient's diarrhea was thought to be a component of her GVHD, secondary to the withdrawl of her cyclosporine. Methylpred was started at 30IV [Hospital1 ] and has been tapered to 10 daily. C.diff was negative. Repeat C. diff has been sent. Patient has had loose stools with taper, but she is not having the explosive diarrhea she had on presentation. . 4. DIC- Patient's developed DIC after receiving hydroxyurea. She received multiple transfusions. She has no bleeding on exam but she does have ecchymosis on her arms and back. . 5. Access- Patient's access was initially an issue. She has limitid central access in upper torso, (total occlusion of the left internal jugular vein and subclavian vein, total occlusion of the right subclavian vein, patent right internal jugular vein, although there is a focal narrowing and a filling defect within the superior vena cava between the confluence of the brachiocephalic veins and the insertion of the azygos vein into the SVC.) For this reason she received a right femoral Hickman. . 6. Eczema - On the day of presentation, the patient had a rash which was initially thought to be related to her GVHD. It was located on the dorsal aspects of her hands and lateral aspect of her R malleolus. Derm came by and said that it was a variant of eczema. . 7. Perianal sores - Duoderm Medications on Admission: Acyclovir 400 mg b.i.d. aerosolized pentamidine (last given on [2151-7-17]) voriconazole 200 mg b.i.d. Isordil 15 mg t.i.d. Toprol-XL 100 mg daily Diovan 160 mg b.i.d. allopurinol 150 mg daily Protonix 40 mg daily folic acid one milligram daily multivitamin daily magnesium oxide two tablets daily Ativan 0.5-1 milligram q.4-6h. p.r.n. Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Relapsed AML VRE Bacteremia Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A Completed by:[2151-11-17]	[ "996.62", "995.92", "518.81", "112.0", "286.6", "284.8", "528.0", "288.0", "401.9", "996.85", "575.0", "205.00", "V58.65", "428.0", "293.0", "459.2", "427.31", "038.0", "692.9", "425.4", "570" ]	icd9cm	[ [ [] ] ]	[ "38.93", "99.06", "96.71", "33.24", "99.15", "96.04", "00.14", "99.04", "99.05", "99.07", "99.25", "86.11" ]	icd9pcs	[ [ [] ] ]	11005, 11014	8255, 10587	348, 380	11085, 11094	7766, 8232	11146, 11181	6889, 6999		10977, 10982		11035, 11064		10613, 10954			11118, 11123									7014, 7747																								258, 310										408, 6214															6236, 6395	6411, 6873
30,962	180,652	10562	Discharge summary	report	Admission Date: [2200-8-4] Discharge Date: [2200-8-28] Date of Birth: [2141-12-31] Sex: F Service: MEDICINE Allergies: Reglan / Bactrim / Labetalol / Norvasc / Codeine / Zocor Attending:[First Name3 (LF) 1928] Chief Complaint: Fever Major Surgical or Invasive Procedure: [First Name3 (LF) ] w/ stent replacement. R IJ tunneled line placement percutaneous intrahepatic drain placement and repositioning and upsizing History of Present Illness: HPI: Ms [Known lastname 34763] is a 58 yo f with h/o DM1, CRI, PVD, CAD s/p CABG who was recently hospitalized for R SFA stent/plasty. She reports feeling well since her recent discharge on [2200-7-31] until this morning. Today she was found at home by her son confused and agitated. She was brought to an OSH where she was found to be febrile to 105 F with a positive UA. Due to her confusion and abdominal discomfort, CT head and abdomen were performed and were reportedly negative. She was pan-cultured, started on IV levaquin for presumed UTI, given 1400cc IVF and transferred to [Hospital1 18] for continuity of care. . In the ED, VS: T 99.5 BP 108/68 HR 76 RR 18 SpO2 100% RA. She received one dose of IV vancomycin, morphine 2 mg IV, 500 cc IVF prior to transfer to the medicine floor. . On arrival to the floor patient's primary complaint is feeling cold and tired. She denies any fevers, abdominal pain, dysuria, nausea, vomiting, chest pain, shortness of breath, or dizziness. . Past Medical History: MEDICAL & SURGICAL HISTORY: 1. Coronary artery disease status post 4v CABG in [Month (only) 1096] of [2190]. 2. DM1 complicated by retinopathy, neuropathy, nephropathy, gastroparesis on insulin pump. 3. Hypertension. 4. Chronic renal insufficiency with a baseline creatinine of 6.5. 5. Hyperlipidemia. 6. Hypothyroidism. 7. Anemia. 8. Left lung decortication secondary to pleural effusion in [2191-12-12]. 9. Vancomycin resistant enterococcal infection. 10. Peripheral vascular disease. 11. C section x2. 12. Gout 13. h/o Peptic ulcer disease (EGD [2196] with erosive gastritis, hiatal hernia, gastroparesis) 14. R SFA stenting and angioplasty [7-/2200] Social History: Unemployed, lives with her son, denies etoh, tobacco, or illicit drug use. She lives with her son in [Name (NI) ]. Unemployed. She quit tobacco in [2190], but has a 30 pack year smoking history. She does not drink. She has one dog at home. Family History: Diabetes, chronic renal insufficiency, coronary artery disease, asthma and thyroid disease. Physical Exam: PHYSICAL EXAM on admission: Vitals - T: 97.6 BP: 132/60 HR: 77 RR: 18 02 sat: 100% GENERAL: shivering, appears chronically ill, NAD, conversant, aox 3 HEENT: NCAT, EOMI, mmm, no oral lesions, poor dentition CARDIAC: RRR, no MRG LUNG: CTA B, no crackles, no wheezes, nonlabored breathing ABDOMEN: distended, PD catheter in place, tenderness on lateral abdomen, no CVA tenderness, no guarding or rebound EXT: warm, dry, no edema or cyanosis, dopplerable pulses bilaterally NEURO: no focal deficits, moves all 4 extremities, CN 2-12 grossly intact DERM: no rashes, ulcers . Pertinent Results: On admission [2200-8-4]: WBC-22.6# RBC-2.40 Hgb-7.8* Hct-24.2* MCV-101* MCH-32.4* MCHC-32.1 RDW-15.2 Plt Ct-318 Neuts-91.3* Lymphs-3.8* Monos-4.7 Eos-0.1 Baso-0.2 PT-30.8* PTT-38.4* INR(PT)-3.1* Glucose-152* UreaN-42* Creat-6.5* Na-140 K-3.6 Cl-100 HCO3-27 AnGap-17 ALT-46* AST-58* CK(CPK)-1186* AlkPhos-149* Lipase-10 CK-MB-10 MB Indx-0.8 cTropnT-0.14* Glucose-146* Lactate-2.1* K-3.7 Cardiac enzymes: [2200-8-4] 06:30PM BLOOD CK-MB-10 MB Indx-0.8 cTropnT-0.14* [2200-8-5] 10:50AM BLOOD CK-MB-13* MB Indx-1.0 cTropnT-0.31* [2200-8-5] 07:34PM BLOOD CK-MB-20* MB Indx-1.3 cTropnT-0.50* [2200-8-6] 02:48AM BLOOD CK-MB-21* MB Indx-1.2 cTropnT-0.74* [2200-8-6] 11:13AM BLOOD CK-MB-15* MB Indx-1.1 MICROBIOLOGY: Blood Cx: [8-4] and [8-5] with enterococcus (sensitivities listed below.) All subsequent blood cultures since then negative. ENTEROCOCCUS SP. \| ENTEROCOCCUS SP. \| \| AMPICILLIN------------ 16 R 16 R PENICILLIN G---------- 16 R 32 R VANCOMYCIN------------ <=1 S <=1 S . U/A: Large blood, protein, moderate leuks, small bilirubin URINE CULTURE: GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML.. . FECAL CULTURE (Final [2200-8-10]): NO SALMONELLA OR SHIGELLA FOUND. NO ENTERIC GRAM NEGATIVE RODS FOUND. CAMPYLOBACTER CULTURE (Final [2200-8-10]): NO CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST Negative x 4. . Peritoneal Dialysate Analysis: WBC RBC Polys Lymphs Monos Eos Basos Mesothe Macro Other [2200-8-25] 12:23AM 145* 3* 44* 26* 19* 2* 4* 2* 31 PERITONEAL DIALYSATE [2200-8-22] 06:19PM 104 2* 64* 20* 0 1* 2* 13* PERITONEAL DIALYSATE [2200-8-20] 02:07PM 275* 20* 71* 5* 18* 2* 4* PERITONEAL DIALYSATE FLUID [2200-8-18] 07:00AM 430* 170* 73* 9* 0 6* 1* 3* 6* 22 PERITONEAL DIALYSATE [2200-8-16] 12:23PM 790 85* 85* 0 11* 3* 1* . Bile Culture: [8-15] [Female First Name (un) ] (TORULOPSIS) [Female First Name (un) ]. SPARSE GROWTH STRAIN 1. [Female First Name (un) ] ALBICANS. SPARSE GROWTH STRAIN 2. Dialysis Culture: [8-18] and [8-20], but No Growth on [8-25] culture [Female First Name (un) ] (TORULOPSIS) [Female First Name (un) ]. IMAGING: CT A/P [8-6]: IMPRESSION: 1. Bilateral ground glass opacities within the lungs may be related to multifocal pneumonia. 2. Given abnormal common bile duct stent position in combination with intrahepatic biliary ductal dilatation, the large ill-defined and irregular left hepatic hypodensity is felt to represent an abscess secondary to ascending cholangitis. At this time, an [Month/Year (2) ] is recommended with stent replacement. If patient does not improve clinically, repeat imaging can be obtained in 48 hours and eventually percutaneous aspiration can be considered. 3. Calcified bladder wall. 4. Patent lower extremity vessels and right SFA stent graft with multifocal areas of narrowing involving the left popliteal and trifurcation vessels as well as the left SFA and popliteal arteries secondary to both calcified and noncalcified atherosclerotic plaque. . CXR [8-7]: A new large region of right perihilar consolidation though accompanied by progression of mild pulmonary edema in the left lung, and probable increase in small left pleural effusion should be considered pneumonia until proved otherwise. Borderline cardiomegaly is stable. Right jugular central line projects over a vascular stent ending in the low SVC. No tracheostomy tube. . ECHO [8-6]: Mild symmetric left ventricular hypertrophy with normal systolic function. No vegetations identfied. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. Compared with the report of the prior study (images unavailable for review) of [2191-12-8], the severities of mitral regurgitation and tricuspid regurgitation have increased. Moderate pulmonary artery systolic hypertension is now detected. . EKG [8-7]: Poor R wave progression. Cannot rule out old anteroseptal myocardial infarction. Modest inferolateral ST-T wave changes which are non-specific. Compared to the previous tracing of [2200-8-6] there is no significant diagnostic change. . [Date Range ] [8-11] Old biliary stent removed Sludge/stone like filling defect in distal CBD Since the patient was on ASA and Plavix, a sphinterotomy was not performed New biliary stent placed with good flow of bile . CXR [8-12]: Relative to the prior exam, there has been marked improvement with no definite focal consolidation or superimposed edema noted at the current time. There is poor definition of the left costophrenic angle which may be at least in part technical. Attention on follow up radiographs is recommended. . HEAD CT [8-13]: No hemorrhage or edema. Evident mild small vessel ischemic disease. . US HEPATOTOMY DRAIN ABSCESS/CYST [8-15]: Successful ultrasound-guided placement of an 8-French drainage catheter into a large left hepatic abscess/biloma. . [Numeric Identifier 4684] FLUORO GUID PLCT/REPLCT/REMOVE CENTRAL LINE [8-15] Successful repositioning of the right PICC line with the tip terminating in the subclavian vein. The line is ready to use. . CXR [8-17]: stent in the SVC is unchanged. Sternal wires are again visualized. A catheter is seen overlying the left upper quadrant. A right-sided PICC line tip is difficult to visualize. It is at least in the SVC. The lungs are clear without infiltrate or effusion. . EKG [8-19] Sinus rhythm. Lead V5 unsuitable for analysis. Compared to the previous tracing of [2200-8-7] there is no change. . CT ABDOMEN [8-25] 1. Redemonstration of left and right hepatic hypodense collections. The collection on the left overall appears slightly smaller, though now contains a larger portion of gas, presumably related to the drainage catheter in place. The collection on the right is minimally changed. 2. Ascites and free gas within the abdomen, presumably a sequela of peritoneal dialysis. 3. Fat-containing ventral abdominal wall hernia. 4. Numerous renal hypodensities bilaterally, some of which appear to be cysts, of other which are incompletely characterized. Recommend attention paid to these areas on followup imaging. . CT ABDOMEN [8-25] Left lobe abscess has slightly decreased in size as compared to the previous study. Drainage catheter can be pulled out 3-4 cm for a more adequate drainage. Right lobe abscess has similar size. . DOPPLER IJ VEINS [8-27] Patent internal jugular veins bilaterally. Please note that the left internal jugular vein is of small caliber. Brief Hospital Course: 58 year-old DM I, PVD, ESRD on PD, CAD s/p CABG who was presented with polymicrobial sepsis, 1week after d/c for R SFA stent/plasty (d/c [7-31]). Presented to OSH with fevers and positive UA. Transferred to [Hospital1 18], found to have displaced biliary stent and two hepatic abscesses, likely [1-13] cholangitis. Now s/p [Month/Day (2) ] [8-11], s/p hepatic abscess drainage and hepatic drain placement [8-15], which reveal [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 563] in abscess and dialysis fluid. Current antimicrobial regimen: vancomycin, cipro, flagyl, micafungin. #Bacteremia/Fungal Peritonitis: On presentation, the patient was febrile to 105 and was found to have enterococcus and pan-sensitive Klebsiella in blood cultures. She was initially managed with vanc/zosyn but then switched to daptomycin in place of vancomycin when sensitivies demonstrated VRE. She also received aggressive IVF resuscitation and underwent a TTE that was negative for vegetation. Her polymicrobial septicemia was found to be secondary to displaced biliary stent (seen on CT) associated with two liver abscesses. On [2200-8-11], she was transferred to the [Hospital Unit Name 153] for an [Hospital Unit Name ], during which old biliary stent removed and new biliary stent was placed with good flow of bile. After stabilization, she was transferred to medicine floor. On floor, for bacteremia, she was maintained on zosyn (for GNRs and anaerobes) and daptomycin (for VRE). Repeat CT imaging showed persistent large (6x8cm) left lower hepatic lobe abscess and smaller (2x2cm) right hepatic lobe abscess. Left hepatic lobe abscess was drained and cultured on [8-15] and a hepatic drain was left in place. of abscess fluid grew yeast. Simultaneously, [8-16] dialysis fluid cx's also grew yeast-[First Name5 (NamePattern1) 564] [Last Name (NamePattern1) ]. Pt was started on micafungin. The hepatinc train had only suboptimal output, and repeat CT after one week of drainage showed only small interval decrease with loculated component. The drain was repositioned on [8-25]. With worsening abdominal discomfort, rising WBC count from abdominal fluid, and lactate rise to 3.0 (now 1.6) the patient's PD catheter was removed by the transplant surgery team on [8-26]. Sensitivities were obtained were modified for the Enterococcus on [8-27], demonstrating sensitivity to vanco. Given that and her clinical improvement, one day prior to admission, her antimicrobial regimen was changed to vancomycin (for enterococcus), cipro (for GNRs), flagyl (for anaerobes), and micafungin (for fungal peritonitis). Final pathology on the PD catheter tip is pending. Given only small improvement in output from intrahepatic drain after repositioning, the patient had her drain upsized on the day of transfer. Please see ID sign out note, but they would plan on 4 weeks of micafungin treatment from removal of PD catheter on [8-26]. They would persue a short course of continued antibiotics after removal of hepatic drain. The patinet has been afebrile for over 2 weeks prior to transfer. Please contact Dr. [Last Name (STitle) 13895] at [Telephone/Fax (1) 457] with questions or concern. Outpatient follow-up with Dr. [Last Name (STitle) 15180] for repeat [Last Name (STitle) ] with sphincterotomy (which could not be performed because pt was on plavix) and brushings in 12 weeks once she can be safely off her plavix for 7 days is recommended. #Elevated Cariac Markers: She has a history of CAD s/p CABG. In the setting of her sepsis, the patient had evidence of cardiac demand ischemia, with troponin rise to 0.7, CK-MB to 25, and CK to 1700. The likely etiology of this increase in cardiac markers is more demand ischemia versus an acute coronary event. While her CK rise was prominent, it was dispropotional to MB rise with only minor rise of her index. Additionally, the troponin rise is in the setting of ESRD. These were thought to be a combination of CK rise from possible myositis in her lower extremities given diffuse thigh pain, along with demand ischemia. She was continued on aspirin and plavix, the latter which she had been started on after her SFA stent. The aspirin was eventually held given plan [Last Name (STitle) ]. Beta blockade was avoided in ICU because of her relative hypotension. Once hemodynamically stable and LFTs normalized on medicine floor, beta-blocker and statin were restarted at home-dose. ASA was held prior to each IR procedure she had (insertion of hepatic drain, repositioning of hepatic drain) and will need to be re-started 24hrs after on [8-29]. # Elevated LFTs: Transaminitis were thought to be secondary to hepatic abscess and/or shock/ischemic liver. She underwent [Month/Year (2) ] and new stent was placed, LFTs improved. ALT and AST rose to 700 and 1000 respectively on [8-8], and have been normalized since [8-18]. # ESRD: She has ESRD and was admitted on peritoneal HD. Her ESRD is secondary to diabetic nephropathy. Nephrology followed her during this admission. She was found to have fungal peritonitis (dialysis fluid cx's grew [First Name5 (NamePattern1) 564] [Last Name (NamePattern1) ]), and it was decided that her PD catheter was a nidus of infection, and was removed without complication on [8-26]. Plan to transition to HD temporarily for [12-13] until antimicrobial therapy can clear abscesses. She had done well throughout admission on PD. Dopplers of IJ veins day prior to d/c showed patent IJ veins, but left IJ small caliber. A right IJ tunneled line was placed without complications. The patient requested transfer to [Hospital3 ] for further manegment by her home nephrologist. # UTI: At [Hospital1 18], she was found to have Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. She had coverage for this with her broad-spectrum antibiotics. Her urine culture from outside hospital grew Staph Lugdunensis, which was covered by broad-spectrum antibiotics. However, given the high association between Staph Lugdunensis and endocarditis, ID consultants recommended an outpatient TEE to rule out endocardial damage/vegetations. Given no stigmata of endocarditis and no evidence of bacteremia, this recommendation was ammended. # PVD: The patient recently underwent stent of R SFA, which raised concern of compartment syndrome on admission. However, the vascular service felt that this was unlikely. Pt was continued on Plavix. ASA and coumadin were held for [Hospital1 ]. ASA was restarted 72 hours after. It was confirmed with outpatient nephrologist that coumadin was being administered to prophylactically keep potential HD catheter sites patent, but that outpatient nephrologist was OK with holding coumadin for period of weeks/months while in hospital. So coumadin was held for the duration of her stay. The patients plavix was held for upsizing of hepatic drain, and will need to be restarted on [8-29]. #DM1: She has DM1 that is complicated by retinopathy, neuropathy, nephropathy, and gastroparesis. In the MICU, she was started on an insulin ggt [First Name8 (NamePattern2) ] [Last Name (un) 387] recs for poorly controlled finger sticks in the setting of infection, then transitioned to on a basal lantus regimen with ISS. On the floor, she was continued on basal lantus and ISS which was adjusted with the continued assistence of the [Last Name (un) ] consult. #Diarrhea: Patient has been with loose stool since arrival on medicine floor [8-13]. Likely [1-13] antibiotics altering gut flora. Stool cx [8-8] neg for Campylobacter, C.Diff toxin A and B, enteric GNRs, salmonella, shigella. C.diff toxin neg [8-8], [8-14], [8-17], [8-20]. # Hypothyroidism: Continued her home levothyroxine throughout hospital stay. # Seizure d/o: Pt was maintained on Keppra prophylaxis. No active seizure activity. Son stated that she was put on this b/c last year during a hospital admission, she had an isolated seizure episode, none since, none before. The Keppra dose seems low, but we continued it and will defer to PCP to discontinue or make dose changes. Medications on Admission: Home Medications: Per admission note Plavix 75 mg daily Omega-3 Fatty Acids Capsule [Hospital1 ] B Complex-Vitamin C-Folic Acid 1 mg daily Rosuvastatin 20 mg daily Pantoprazole 40 mg [Hospital1 ] Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Losartan 100 mg daily Levothyroxine 150 mcg daily Levetiracetam 500 mg daily Lanthanum 1000 mg TID with meals Lactulose 30 mL TID Gabapentin 200 mg qhs Doxercalciferol 2 mcg daily Clonidine 0.2 mg/24 hr Patch Weekly (Saturday) Dicyclomine 20 mg qid Ranitidine HCl 150 mg BIC Senna 8.6 mg Tablet daily Acetaminophen 1000 mg TID prn Insulin pump Coumadin 4 mg daily Gentamicin 0.1 % Cream Sig: qd prn around catheter Metoprolol Succinate 50 mg daily . Transfer Medications from MICU to [Hospital Unit Name 153] [2200-8-8]: Acetaminophen 650 mg PO Q6H:PRN pain or fever Morphine Sulfate 2 mg IV Q6H:PRN pain Ondansetron 4 mg IV Q8H:PRN nausea Levothyroxine Sodium 150 mcg PO DAILY LeVETiracetam 500 mg PO DAILY Lanthanum 1000 mg PO TID W/MEALS Gabapentin 200 mg PO HS Senna 1 TAB PO BID Docusate Sodium 100 mg PO BID Fish Oil (Omega 3) 1000 mg PO BID Doxercalciferol 2 mcg PO DAILY Nephrocaps 1 CAP PO DAILY Bisacodyl 10 mg PO DAILY:PRN constipation Ranitidine 150 mg PO DAILY Piperacillin-Tazobactam 2.25 g IV Q12H Insulin 100 Units/100 ml NS @ [2-20] UNIT/HR IV DRIP INFUSION Lactulose 30 mL PO Q8H:PRN constipation Rosuvastatin Calcium 10 mg PO DAILY Metoprolol Tartrate 25 mg PO BID Nystatin Cream 1 Appl TP [Hospital1 ] Miconazole Powder 2% 1 Appl TP [Hospital1 ]:PRN rash Linezolid 600 mg IV Q12H Insulin SC Plavix 75mg qd ASA 81 mg qd Discharge Medications: 1. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Doxercalciferol 0.5 mcg Capsule Sig: Four (4) Capsule PO DAILY (Daily). 4. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous X1 (ONE TIME) for 1 doses. 6. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours). 10. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 11. Micafungin 100 mg Recon Soln Sig: One (1) Recon Soln Intravenous DAILY (Daily). 12. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 15. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 17. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 18. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every [3-17] hours as needed for fever or pain. 19. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for nausea. Discharge Disposition: Extended Care Facility: [Hospital3 3765] - [Location (un) 1514] Discharge Diagnosis: #Polymicrobial Sepsis #Fungal Peritonitis #ESRD #Coronary Artery Disease/Demand Ischemia #Type 1 Diabetes Mellitus Secondary: #Hypothyroidism #Peripheral Vascular Disease #Hypertension Discharge Condition: Stable. Discharge Instructions: You were admitted with polymicrobial sepsis, most likely from a displaced and infected biliary stent. You were treated with aggressive antibiotics for the bacteria in your blood. The stent was removed and replaced. Because of this infection, you had abscesses in your liver, which were drained, however not completely. You are being transferred to [Hospital3 3765] with a drain still in place in one of the abscesses in your liver and continuing on antifungals and antibiotics. You will require a trans-esophageal echocardiogram in the future to make sure you have no bacteria on your heart valves. This should be coordinated by your infectious disease doctor. When you were admitted to the hospital, your insulin pump had run out of insulin. You were put on an insulin drip in the ICU, and after stabilization, your blood sugars were managed with basal lantus and insulin sliding scale. During your ICU stay, you had experienced some episodes of low blood pressure as a complication of your infection. Combined with your predisposition to heart disease, given your diabetes, your heart experienced a minor heart attack. After all your procedures were done, you were restarted on aspirin, metoprolol, and crestor to protect your heart. Also, prior to this hospitalization, you recently had a stent placed in your leg. During this hospitalization, you were maintained on plavix as much as possible (given all your procedures) to protect your stent. You will be followed-up by vascular surgery at some point in the future. In addition, at some point in the future when you can be off plavix for 7days, you will require repeat [Hospital3 ]. This can be coordinated by an outpatient gastroenterologist. Followup Instructions: Outpatient follow-up with Dr. [Last Name (STitle) 15180] for repeat [Last Name (STitle) ] with sphincterotomy (which could not be performed because pt was on plavix) and brushings in 12 weeks once she can be safely off her plavix for 7 days is recommended. Provider: [Name10 (NameIs) 1948] [Last Name (NamePattern4) 1949], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2200-10-30] 11:00 Provider: [Name Initial (NameIs) ] 2 (ST-4) GI ROOMS Date/Time:[2200-10-30] 11:00 Pt Currently has a ID f/u given below. Also can follow up with ID staff at [Hospital1 ]. [First Name11 (Name Pattern1) 1037] [Last Name (NamePattern4) 2335], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2200-9-10] 10:30	[ "585.6", "567.29", "572.0", "403.91", "996.68", "345.90", "285.9", "599.0", "038.0", "996.59", "576.1", "785.52", "414.00", "250.63", "V45.11", "570", "362.01", "272.4", "995.92", "V45.81", "038.49", "357.2", "250.53", "576.2", "250.43" ]	icd9cm	[ [ [] ] ]	[ "38.95", "97.82", "50.91", "38.93", "51.87" ]	icd9pcs	[ [ [] ] ]	21542, 21616	9998, 18260	323, 473	21846, 21856	3184, 3578	23615, 24359	2483, 2576		19934, 21519		21637, 21825		18286, 18286			21880, 23592									2591, 2605					18305, 19911															3595, 9975				278, 285										501, 1504									2619, 3165						1526, 2201	2217, 2467
67,188	108,429	37649	Discharge summary	report	Admission Date: [2115-12-26] Discharge Date: [2116-1-3] Date of Birth: [2032-5-26] Sex: M Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7733] Chief Complaint: squamous cell carcinoma of scalp eroding through cranium to the dura Major Surgical or Invasive Procedure: 1. wide-excision of squamous cell carcinoma of scalp 2. craniotomy 3. dural excision and dural replacement using anterior rectus fascia 4. free right rectus muscle flap to cranium using superficial temporal vessels on the right 5. split-thickness skin graft to vascularized muscle flap 6. mesh closure of abdomen 7. excision of squamous cell carcinoma of the right helical rim of ear (3 x 1 cm) 8. plastic closure of the ear excision site History of Present Illness: 83 year old male who has been followed initially in [State 1727] over the past decade for multiple basal cells and squamous cells involving the head and neck region. He has had multiple previous procedures. We first met him with a radiation related problem[Name (NI) 115] nonhealing ulcer on the nose with recurrent tumor. This was eventually widely excised and he is now missing the right half of his nose. He does not wished to have any reconstruction for this. Problem[Name (NI) 115] over the past year has been an erosive ulcer involving the dome of the cranium. This has been open for least 4-6 months. MRI was obtained that showed erosion through the outer and inner table of the skull just to the right of the superior sagittal sinus in the upper parietotemporal region with accumulation of tissue on the dura. Past Medical History: 1. Dyslipidemia 2. Hypertension 3. Non-Hodgkin's lymphoma(dx 6-7yrs ago-in remission per hospital notes) 4. Melanoma to cheek, s/p resection & STSG [2110] 5. s/p LLL lobectomy [3-/2115](also w/known mediastinal and axillary lesions)-Path per hospital records Stge IB Non-small cell lung cancer 6. Small cell carcinoma to right head, s/p STSG [10/2115] 7. s/p Left THR [2111] 8. s/p Right Knee arthroscopy Social History: resides at home in [State 1727], capable of self-care, lives independently tobacco: 40pack-year history, quit 40 years ago EtOH: occasional alcohol use denies ilicit drug use Family History: father and sister with cancer diagnosis (nonspecific details) Physical Exam: upon admission: General: alert and oriented x3 HEENT: wide surgical excision of right nose, skin lesion right scalp Chest: clear to auscultation on right, coarse breath sounds on left CV: RRR Abdomen: soft, nontender, nondistended Ext: no BLE edema appreciated Pertinent Results: [2115-12-26] 05:57PM TYPE-ART PO2-384* PCO2-36 PH-7.46* TOTAL CO2-26 BASE XS-2 [2115-12-26] 05:57PM freeCa-1.10* [2115-12-26] 05:40PM GLUCOSE-138* UREA N-18 CREAT-0.9 SODIUM-141 POTASSIUM-3.8 CHLORIDE-112* TOTAL CO2-22 ANION GAP-11 [2115-12-26] 05:40PM estGFR-Using this [2115-12-26] 05:40PM CALCIUM-7.9* PHOSPHATE-2.7 MAGNESIUM-1.3* [2115-12-26] 05:40PM WBC-8.4 RBC-3.36# HGB-10.5# HCT-30.2# MCV-90 MCH-31.3 MCHC-34.9 RDW-13.1 [2115-12-26] 05:40PM PLT COUNT-204 [2115-12-26] 03:13PM PO2-172 PCO2-42 PH-7.40 TOTAL CO2-27 BASE XS-1 [2115-12-26] 03:13PM GLUCOSE-107* LACTATE-0.7 NA+-140 K+-3.7 CL--110 [2115-12-26] 03:13PM HGB-10.5* calcHCT-32 [2115-12-26] 03:13PM freeCa-1.11* [2115-12-26] 10:28AM TYPE-ART PO2-116* PCO2-43 PH-7.41 TOTAL CO2-28 BASE XS-2 [2115-12-26] 10:28AM GLUCOSE-105 LACTATE-0.8 NA+-140 K+-3.6 CL--111 [2115-12-26] 10:28AM HGB-11.0* calcHCT-33 O2 SAT-98 [2115-12-26] 10:28AM freeCa-1.10* Brief Hospital Course: The patient was admitted to the plastic surgery service on [2115-12-26] and had a wide-excision of squamous cell carcinoma of scalp, craniotomy, dural excision and dural replacement using anterior rectus fascia, free right rectus muscle flap to cranium using superficial temporal vessels on the right, split-thickness skin graft to vascularized muscle flap, mesh closure of abdomen, excision of squamous cell carcinoma of the right helical rim of ear (3 x 1 cm), plastic closure of the ear excision site, the patient tolerated the procedure well and was admitted to the SICU post-operatively. Neuro: Post-operatively, the patient received morphine IV and percocet with good effect and adequate pain control. Upon transfer to the inpatient floor, patient experienced significant delirium and agitation with worsening symptoms at night. Patient was noted to have had a paucity of uninterrupted sleep post-operatively in the SICU. Patient was closely monitored by the primary team, nursing, and family and effort was made to provide a dark, quiet environment to facilitate rest. The following day, he showed marked improvement in symptoms and his delirium did not return for the remainder of this admission. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. His diet was advanced when appropriate and was tolerated well. He was also started on a bowel regimen to encourage bowel movement. The foley catheter was removed on [12-30]. Intake and output were closely monitored. ID: Post-operatively, the patient was started on IV cefazolin, then switched to PO cephalexin on POD#2 until discharge. The patient's temperature was closely watched for signs of infection. Prophylaxis: The patient was provided with pneumatic boots and encouraged to get up and ambulate as early as possible. At the time of discharge on POD#8, the patient, rectus flap, and surgical sites were doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Medications on Admission: aspirin atenolol atorvastatin amlodipine Discharge Medications: 1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable 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). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:20 Capsule(s) Refills:2 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: southern [Hospital ] medical center VNA, Discharge Diagnosis: squamous cell carcinoma of scalp eroding through cranium to the dura Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: - Avoid caps, stockings, or other headwear that place pressure on your graft site - Keep your skin graft donor site clean and dry at all times - You may clean around the area of your head flap with normal saline - You may shower but avoid direct waterfall onto your head flap and keep a tegederm over the skin graft donor site on your leg - Do not remove the steristrips on your abdominal incision, you may trim them at the edges when there lose adherence to the skin. The steristrips will fall off on its own in [1-18] weeks. Call Dr[Name (NI) 23346] office or return to the ER if: * You notice significant changes in your flap, surgical incision site, or skin graft site - to include color, swelling, drainage, and pain * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. Followup Instructions: please call Dr[Name (NI) 23346] office at [0-0-] to schedule a follow-up visit [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(1) 7738] Completed by:[2116-1-3]	[ "401.9", "198.4", "173.2", "173.4", "197.6", "202.80", "V15.3", "198.5", "272.4", "162.5", "V43.64", "V10.82", "274.9", "293.0" ]	icd9cm	[ [ [] ] ]	[ "86.4", "02.12", "54.72", "83.82", "86.69", "02.06", "18.29", "01.51" ]	icd9pcs	[ [ [] ] ]	6819, 6894	3734, 5999	383, 824	7007, 7007	2708, 3711	8671, 8910	2346, 2410		6090, 6796		6915, 6986		6025, 6067			7152, 8648									2425, 2427																								275, 345										852, 1689									2442, 2689		7021, 7128				1711, 2133	2149, 2330
7,882	169,472	12134+12135	Discharge summary	report+report	Admission Date: [2103-2-23] Discharge Date: [2103-3-15] Date of Birth: [2055-5-8] Sex: M HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old man with a sudden onset of loss of consciousness on the morning of admission. His wife witnessed shaking and frothing activities for about 2-3 minutes. The patient awoke with memory of the fall or syncope and never had signs or symptoms before like this. Now feels woozy, lightheaded but not confused or disoriented. Full sensory, motor intact. Now ambulating without difficulty. CT at the outside hospital shows a colloid cyst of the third ventricle. He was transferred to [Hospital1 69] for further management. PAST MEDICAL HISTORY: Includes hypercholesterolemia, MVR in [2097] on Coumadin, status post ablation and cardioversion, hypertension, GERD, CHF, Dressler's syndrome and hepatitis C. PHYSICAL EXAMINATION: He is in no acute distress. His vital signs are stable. His pupils are equal, round and reactive to light. Extraocular movements intact. Bilateral upper and lower extremities are [4-22], reflexes are 2+ throughout. He is ambulating normally. His EKG was normal on admission. His Chem 7, sodium 141, potassium 3.8, chloride 104, CO2 27, BUN 11, creatinine .9, glucose 99. Coags on admission, PT 25, INR 4.1 and his PTT was 33. HOSPITAL COURSE: The patient was started on Heparin. His INR was allowed to drift down to the 2.5 range and then he was started on Heparin. Cardiology assessed him and felt that it was important to continue the Heparin and that once he was able to start back on Coumadin, that his INR be 2.5 to 3.0. On [2103-3-1] the patient underwent transcollossal resection of colloid cyst. The patient was monitored on the surgical Intensive Care Unit post-op. His blood pressure was 120/50, heart rate 95, sats 95% on two liters. Neurologically the patient was awake and alert, oriented times two, following commands with a decreased affect and decreased motor strength of the left upper extremity. On postoperative day #1 the patient underwent head CT which revealed a venous infarct on the right frontal lobe. The patient remained in the Intensive Care Unit with close neurologic evaluation. He had a slight interval increase in the size of the right frontal lobe bleed and infarct. On [2103-3-5] the patient had a repeat head CT which showed slight interval increase in the size of the infarct and edema. The patient was continued to be monitored in the surgical Intensive Care Unit, neurologically remained awake and alert, oriented times [1-21], and continued to have some decreased strength in the left upper extremity. The patient was restarted on Heparin on [2103-3-7] and remained stable neurologically on IV Heparin. He was started on po Coumadin [2103-3-8]. He was transferred to the regular floor on [2103-3-7] in stable and neurologic condition. His left upper extremity weakness improved. He was out of bed ambulating, tolerating regular diet, voiding spontaneously and became therapeutic on his Coumadin on [2103-3-14]. He was discharged home in stable condition with follow-up with Dr. [First Name (STitle) ] in one month time. His incision was clean, dry and intact at the time of discharge and his vital signs remained stable. He will follow-up with his primary care physician for his Coumadin treatment. [First Name11 (Name Pattern1) 125] [Last Name (NamePattern4) 342], M.D. [MD Number(1) 343] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2103-3-14] 11:04 T: [2103-3-14] 11:16 JOB#: [Job Number 38027] Admission Date: [2103-2-23] Discharge Date: [2103-3-18] Date of Birth: [2055-5-8] Sex: M Service: NEUROSURGERY CHIEF COMPLAINT: Syncope and question of seizure. HISTORY OF PRESENT ILLNESS: This is a 47 year old gentleman with sudden loss of consciousness the morning of admission. The wife witnessed "shaking and frothing" activity for confusion but had full recall from the time of awakening. There was no memory of the fall or syncope. The patient never had symptoms before like this. The patient felt woozy and light-headed but was not confused or disoriented. There was full sensory and motor function intact by the time the patient arrived to the Emergency Department The patient had a CT at an outside hospital prior to transfer to the [Hospital1 69] Emergency Department that showed a "colloid cyst at the take-off of the third ventricle". The patient was transferred to [Hospital1 346] for further workup. PAST MEDICAL HISTORY: Significant for: 1. Hypercholesterolemia. 2. Mitral valve replacement, question rheumatic heart disease, in [2097]. The patient is chronically on Coumadin. 3. Status post ablation and cardioversion. 4. Hypertension. 5. Gastroesophageal reflux disease. 6. Congestive heart failure. 7. Dressler's syndrome. 8. Hepatitis C. MEDICATIONS ON ADMISSION: 1. Toprol XL 200 mg p.o. q.d. 2. Maxzide 25 mg p.o. q.d. 3. Colchicine 0.6 mg p.o. q.d. 4. Zocor 40 mg p.o. q.d. 5. Nexium 40 mg p.o. q.d. 6. Coumadin 9 mg five days a week and 10 mg on the weekends. 7. Oxycontin 40 mg p.o. q.d. 8. Combivent two puffs b.i.d. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: The patient is in no apparent distress with stable vital signs. The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. He had bilateral upper extremity and lower extremity strength and sensation, [4-22] and equal. His reflexes were 2+ bilaterally equally and he ambulated normally. LABORATORY DATA: Admission laboratories showed an INR of 4.1 with a prothrombin time of 25 and partial thromboplastin time was 33. His sodium was 141, potassium 3.8, chloride 104, bicarbonate 27.6, blood urea nitrogen 11 and creatinine 0.9 with a glucose of 99. He had a CT of the head at the outside hospital that showed a colloid cyst that was approximately 1.0 centimeter by 1.0 centimeter at the take-off of the third ventricle. There was no hydrocephalus and no intracranial bleed. HOSPITAL COURSE: The patient is admitted on [2103-2-23], for workup of this colloid cyst and to receive magnetic resonance scan. He was started on a Heparin drip and he was taken off his Coumadin to continue him on anticoagulation for a operative correction of this lesion. The patient was admitted to the service and was seen by cardiology during his preoperative evaluation and it was recommended that he should have a INR of 2.5 to 3.0. He was cleared for surgery, and underwent excision of his mass through a transcollossal approach on [2103-3-1]. He was admitted to the Surgical Intensive Care Unit postoperatively and was doing quite well. He was weaned off Nipride for blood pressure control and continued to be stable neurologically. He was transferred to the floor on postoperative day two. He had a slight difficulty in orientation and verbal speech but this continued to improve. He had some left arm neglect and weakness in the Intensive Care Unit and continued on his Heparin drip for anticoagulation. He was stable on the floor and continued to have some emotional instability. There was CT of the head that showed a right frontal lobe bleed/infarct and a repeat CT in the Intensive Care Unit on [2103-3-4], showed slight increase in this right frontal lobe lesion but no symptomatic changes. With stabilized scan, the patient actually went to the floor on [2103-3-6]. He continued to be stable on the floor although on the evening of [2103-3-8], the patient had an episode of confusion and agitation which required Ativan and Haldol overnight to stabilize him. He continued to have episodes of confusion and anxiety overnight but this was sufficiently treated with p.r.n. Ativan. He continued to improve neurologically and continued to be in-house while his INR was attempted to be raised to the goal therapeutic level of 2.0 to 2.5. He was on Coumadin doses of 7.5 mg originally but was raised to Coumadin doses of 10 mg to get his INR greater than 2.0. On [2103-3-18], his INR was in fact 2.0 and it was decided that he could be discharged with strict follow-up of his INR to keep the goal between 2.0 and 2.5. He will be discharged home in stable condition. DISCHARGE DIAGNOSIS: Status post resection of colloid cyst, third ventricle. FOLLOW-UP: He will follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Hospital 341] Clinic in approximately two weeks. He will continue on his Coumadin regimen at 7.5 mg p.o. q.d. with necessary adjustments for a goal INR of 2.0 to 2.5. MEDICATIONS ON ADMISSION: 1. Toprol XL 200 mg p.o. q.d. 2. Maxzide 25 mg p.o. q.d. 3. Colchicine 0.6 mg p.o. q.d. 4. Zocor 40 mg p.o. q.d. 5. Nexium 40 mg p.o. q.d. 6. Coumadin 7.5 mg p.o. q.d. 7. Oxycontin 40 mg p.o. q.d. 8. Combivent two puffs b.i.d. 9. Ativan 1 mg p.o. q8hours p.r.n. [First Name11 (Name Pattern1) 125] [Last Name (NamePattern4) 342], M.D. [MD Number(1) 343] Dictated By:[Last Name (NamePattern1) 9800] MEDQUIST36 D: [2103-3-18] 08:19 T: [2103-3-18] 08:51 JOB#: [Job Number 38028]	[ "742.4", "300.00", "401.9", "530.81", "272.0", "V43.3", "997.02" ]	icd9cm	[ [ [] ] ]	[ "01.59" ]	icd9pcs	[ [ [] ] ]											8445, 8784		8810, 9362	6225, 8423																								5376, 6207											3862, 3896										3925, 4663															4686, 5021
58,163	141,861	38292	Discharge summary	report	Admission Date: [2186-3-14] Discharge Date: [2186-3-19] Date of Birth: [2151-1-15] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4891] Chief Complaint: nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: 35 yo M w/ h/o DMI c/b gastroparesis, retinopathy, and nephropathy, CKD, HTN presents w/ nausea/vomiting x 1 day. . Pt presents w/ emesis x 1 day. Pt has had ~10 episodes of emesis, around 5th episode noticed streaks of blood. He denies f/c, cough, dysuria, d/c. He was unable to take meds today, including AM lantus dose. . In the ED, VS: T 97, BP 204/126, HR 122, RR 16, 100% RA. While in the [Name (NI) ] pt had coffee ground emesis, GI was consulted and NG lavage placed and cleared after 250cc suction. Pt found to be TTP at RLQ on exam, rectal exam guaiac negative. Labs notable for hct 32.7, wbc 7.1 w/ 80% pmn, Cr 3.8 (baseline 2.8-3.1), AG 19, UA w/ ket, prot, glu. CT abd/pelvis showed nl appendix and no acute intraabdominal process. Pt received 2L NS, protonix, morphine, dilaudid, compazine and zofran iv, lopressor 5mg iv, 10 units regular insulin for FS of 400. NGT came out w/ episodes of emesis. . Currently, pt feels nauseous and tired, but has not had any further episodes of emesis since transfer. . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: -T1DM c/b gastroparesis, retinopathy, CKD stage III, episodes of DKA -HTN -Asthma as a child -[Doctor Last Name 9376] Syndrome Social History: Lives [Location 6409] with his girlfriend and 2 children. Denies cig, ETOH, illicits. Family History: Father with CAD/MI, HLD, DM2. Mother Thyroid [Name (NI) 3730] Physical Exam: ADMISSION EXAM: VS: T 96.3, BP 120/80, HR 84, RR 16, FS 303 GENERAL: Pale, awake and alert. HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM, OP clear. NECK: No LAD LUNGS: CTA bilat, no r/rh/wh. HEART: RRR, no MRG, nl S1-S2. 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&Ox3 Pertinent Results: I. Labs A. Admission [2186-3-13] 08:17PM BLOOD WBC-7.1 RBC-3.80* Hgb-11.8* Hct-32.7* MCV-86 MCH-31.0 MCHC-36.1* RDW-13.6 Plt Ct-227 [2186-3-13] 08:17PM BLOOD Neuts-80.2* Lymphs-15.9* Monos-1.9* Eos-1.1 Baso-0.8 [2186-3-13] 08:17PM BLOOD Glucose-430* UreaN-40* Creat-3.8* Na-140 K-4.5 Cl-103 HCO3-19* AnGap-23* [2186-3-13] 08:17PM BLOOD Albumin-4.0 Calcium-9.4 Phos-3.6 Mg-2.0 [2186-3-16] 05:00AM BLOOD calTIBC-237* Ferritn-155 TRF-182* [2186-3-14] 09:26AM BLOOD %HbA1c-8.5* eAG-197* [2186-3-17] 07:57AM BLOOD TSH-1.9 [2186-3-18] 07:50AM BLOOD Cortsol-16.2 B. Discharge [2186-3-19] 07:35AM BLOOD WBC-5.6 RBC-3.20* Hgb-10.0* Hct-27.3* MCV-85 MCH-31.4 MCHC-36.8* RDW-13.7 Plt Ct-173 [2186-3-19] 07:35AM BLOOD Glucose-233* UreaN-40* Creat-3.3* Na-136 K-3.9 Cl-102 HCO3-26 AnGap-12 [2186-3-19] 07:35AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.6 [2186-3-16] 05:00AM BLOOD calTIBC-237* Ferritn-155 TRF-182* [2186-3-14] 09:26AM BLOOD %HbA1c-8.5* eAG-197* [2186-3-17] 07:57AM BLOOD TSH-1.9 [2186-3-18] 07:50AM BLOOD Cortsol-16.2 C. Urine [2186-3-14] 03:34AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.010 [2186-3-14] 03:34AM URINE Blood-NEG Nitrite-NEG Protein-300 Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [2186-3-14] 03:34AM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-0 II. Microbiology [2186-3-15] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2186-3-14] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2186-3-14] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2186-3-14] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2186-3-14] URINE URINE CULTURE-FINAL INPATIENT III. Radiology A. CXR ([2186-3-14]) HISTORY: 35-year-old male admitted with diabetic ketoacidosis. Evaluation for pneumonia. COMPARISON: Chest radiographs from [2186-2-18]. FINDINGS: The lungs are clear. The cardiomediastinal and hilar contours are normal. There is no vascular engorgement or pleural effusion. The visualized bones and soft tissues are normal. Residual contrast material is seen in the colon. IMPRESSION: Normal chest radiograph. No evidence of pneumonia. B. CT ABD and Pelvis w/o contrast ([2186-3-14]) INDICATION: 35-year-old man with history of diabetic gastroparesis and abdominal pain. COMPARISON: CT of the abdomen and pelvis from [2186-2-17]. TECHNIQUE: MDCT images were acquired through the abdomen and pelvis with oral contrast. Multiplanar reformations were obtained and reviewed. The partially imaged lungs and heart are unremarkable. CT OF THE ABDOMEN WITHOUT IV CONTRAST: The liver, spleen, both adrenals, both kidneys, pancreas, and gallbladder are unremarkable. An NG tube is noted in the stomach. Small and large bowel loops appear unremarkable. The appendix is normal. No abdominal, retroperitoneal, or mesenteric lymphadenopathy by CT size criteria is present. No abdominal free fluid is present. CT OF THE PELVIS WITHOUT IV CONTRAST: The bladder is markedly distended. A stool ball is noted in the rectum. No pelvic or inguinal lymphadenopathy or pelvic free fluid by CT size criteria is present. OSSEOUS STRUCTURES: The visible osseous structures show no suspicious lytic or blastic lesions or fractures. IMPRESSION: 1. Normal appendix. No bowel obstruction or perforation. 2. Markedly distended bladder. 3. Rectal fecal loading. Brief Hospital Course: 35 yo M w/ h/o DMI c/b gastroparesis, retinopathy, and nephropathy, CKD, HTN presents with nausea/vomiting with blood streaks likely from [Doctor First Name ]-[Doctor Last Name ] tear in setting of typical gastroparesis episodes. Secondary issues included DKA on admission from inadequate insulin dosage at home, hypertensive urgency from medication non-adherence at home in setting of acute illness, and hypoglycemia during hospitalization requiring ICU monitoring secondary to insulin stacking in setting of acute renal failure. # Gastroparesis Patient presented with notable nausea and vomiting resulting in poor PO intake. Etiology is likely from severe underlying gastroparesis; however, concurrent DKA likely worsened symptoms or could have been responsible for presentation. Abdominal CT not showing any acute pathology. Other etiologies such as adrenal insufficiency, gastroenteritis not likely. His last gastric emptying study dated [2185-11-10] showed severe delayed gastric emptying with abdominal imaging not suggestive extrinsic or anatomical etiology such as neoplasm responsible for recurrent episodes. He was treated with supportive measurements with resolution and able to take clears. He was continued on his home regimen of reglan, compazine, and erythromycin. The patient may benefit from outpatient evaluation of gastric pacer as he is frequently hospitalized for these episodes. # Probable [Doctor First Name ]-[Doctor Last Name ] tear Patient presented with blood-streaked emesis on admission likely secondary to [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] tear. Given stable Hct, no further episodes, EGD should be considered on outpatient basis to rule out other anatomical lesions such as ulcer. His admission Hgb was 32.7 likely representing hemoconcentration with subsequent Hgb 25.8 near his prior baseline. His discharge Hgb was 27.3. He was discharged on omeprazole 40 mg PO qD. #. Diabetes Type I with diabetic ketoacidosis (Alc 8.5) The patient presented with blood glucose of 430 with anion gap of 18, HCO3 19, and ketonuria consistent with DKA precipitated by concurrent illness and medication non-adherence from illness. The patient's gap closed on the floor with asymptomatic subsequent hypoglycemia to 40s in setting of receiving home dosage of AM glargine and was transferred to MICU for closer fingerstick monitoring. He had further issues with hypoglycemia in setting of insulin stacking in setting of renal failure. Overall, he had brittle glucose measurements during hospitalization with [Last Name (un) ] Diabetes consulted for further management. He was able to take PO consistently and monitored closely. He was discharged on his home lantus 7 units SC qAM and 5 units SC qPM with sliding scale humalog. He was referred to [Hospital ] clinic for further management. #. Acute on Chronic Renal Insufficiency (baseline Cr 2.8): Patient presented with acute on chronic renal failure in setting of diabetes and poor PO intake. His Cr on admission was 3.8 with discharge Cr 3.3. He may also have some component of post-renal component given issues with urinary retention at times during hospitalization from perhaps neurogenic bladder. His renal function should be checked at outpatient follow-up and urology follow-up could be considered if still having voiding difficulties. #. Hypertension: On admission SBP 180-189 in setting of not taking PO anti-hypertensives from nausea/vomiting. His regimen was adjusted during hospitalization given labile blood pressures with initiation of labetalol 100 mg PO BID and continuing clonidine 0.3 mg patch. His lisinopril was discontinued secondary to acute renal failure and re-starting medication should be assessed at outpatient follow-up. # Weight loss: Outpatient evaluation, may have poor caloric intake. # CODE: FULL # Communication: Patient, girlfriend [Name (NI) ] ([Telephone/Fax (1) 85322]) # Transition of care - consider referral for gastric pacer or other therapy for gastroparesis - consider outpatient EGD - [Last Name (un) ] referral for further diabetes management - check Cr at outpatient follow-up - further optimization of blood pressure regimen - work-up for weight loss outpatient Medications on Admission: 1. erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS. 3. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 5. lisinopril 10 mg Tablet Sig: Two (2) Tablet PO once a day. 6. Lantus 100 unit/mL Solution Sig: as directed Subcutaneous twice a day: 7U AM & 5UPM. 7. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous QID ACHS: please continue prior sliding scale. 8. Zofran 4 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for nausea. Discharge Medications: 1. insulin glargine 100 unit/mL Solution Sig: Seven (7) units Subcutaneous QAM. Disp:1000 units Refills:2 2. labetalol 200 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Transdermal once a week. Disp:4 patches Refills:2 4. erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:90 Tablet, Delayed Release (E.C.)(s) Refills:2 5. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS. Disp:120 Tablet(s) Refills:2 6. Zofran 4 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for nausea. Disp:60 Tablet(s) Refills:2 7. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. insulin glargine 100 unit/mL Solution Sig: Five (5) units Subcutaneous qPM. 9. Humalog sliding scale insulin (see attached scale) Discharge Disposition: Home Discharge Diagnosis: Primary: Gastroparesis, Hypoglycemia, Upper Gastrointestinal Bleed, Acute on Chronic Renal Failure Secondary: Type I Diabetes Mellitus 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 related to a gastroparesis flare. Your course in the hospital was complicated by multiple episodes of low blood sugar requiring a brief stay in our intensive care unit. You were seen by our diabetes specialists. We made changes in your insulin regimen and your blood sugars are now under better control. You nausea and vomiting resolved and you are now tolerating a regular diet. . MEDICATION CHANGES: START attached Humalog sliding scale START Labetolol for blood pressure STOP lisinopril Followup Instructions: Dr. [Last Name (STitle) 85323] [Name (STitle) ] Filippis ([Last Name (un) ] Diabetologist) [2186-4-5] at 12:00 (you will also meet with a nurse educator) and have your eyes checked. . Please follow up with Dr [Last Name (STitle) 85321] (Gastroenterology) in 2 weeks for EGD. You will need to call ([Telephone/Fax (1) 85324] to schedule the appointment. Name: [Last Name (LF) ],[First Name3 (LF) ] Location: [Hospital1 641] Address: [Street Address(2) 642], [Location (un) ],[Numeric Identifier 643] Phone: [Telephone/Fax (1) 644] Appt: [3-24] at 12:20pm	[ "E932.3", "V58.67", "584.9", "536.3", "530.7", "E849.7", "250.53", "337.1", "250.83", "277.4", "585.4", "362.01", "250.63", "V15.81", "403.10", "276.1", "250.13", "250.43", "583.81" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	11892, 11898	5833, 10090	321, 328	12077, 12077	2399, 5810	12801, 13415	1909, 1976		10900, 11869		11919, 12056		10116, 10877			12228, 12669									1991, 2380																					12689, 12778			265, 283										356, 1632											12092, 12204				1654, 1786	1802, 1893
23,109	154,812	45050	Discharge summary	report	Admission Date: [2139-1-1] Discharge Date: [2139-1-13] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2108] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ] y/o M with [First Name9 (NamePattern2) 3262] [Last Name (un) 3562] disease, COPD, atrial fibrillation on coumadin, and recurrent transitional cell bladder CA s/p multiple resections (most recent cauterization in [2138-7-20] admitted to the hospital for hematuria, confusion, respiratory distress, and low HCT). At baseline he is somewhat confused but is active and conversant. Per nursing facility today the patient was more somnolent. He was found to have a HCT of 21.6. An attempt was made to schedule an outpatient transfusion, but there was no available appt for > 1 week. The patient had been taking Augmentin and gent at home for PNA (on [12-29] for 7 day [Last Name (un) 10128]). The patient had been experiencing increasing lethargy and difficulty breathing at his skilled nursing facility. In the ED, the patients vital signs were temp 97, HR 64, BP 127/74 RR 32, PaO2: 98%. The patient was short of breath and triggered for a tachypnea with a RR of 32. He was placed on Cpap in the ED. ABG showed Ph 7.4, PaO2 91, PaCO2 46 Bicarb 30. Given dose of albuterol, ipratroprium and methylprednisolone. Pt. already being covered with abx for PNA. A foley was placed and UA performed which showed UTI with WBC of [11-8]. Vancomycin added to abx. regimen. The patient was intially admitted to the MICU. He received Zosyn, 1 unit of blood, and treatment for COPD including non-invasive ventilation. He improved and was transferred to the floor. Past Medical History: 1. prostate ca s/p XRT [2119] 2. bladder ca, papillary urothelial carcinoma, high grade (dx in [2133-3-20]), nonmetastatic (negative cystoscopy [8-24]) -most recent cystoscopy and bladder resection in [2138-7-20] 3. lumbar fracture L5 -- w/multiple steroid injections, previously on chronic opioid therapy 4. COPD (PFTs [12-27]: FVC 89% predicted, FEV1 82% predicted and FEV1/FVC 93% predicted) 5. PUD with GIB in [2120] 6. hx of rheumatic fever 7. hx of CVA 8. s/p appendectomy 9. s/p lap chole in [2122] 10. chronic LE edema 11. tachy-brady syndrome s/p pacer [39]. afib-aflutter not on coumadin due to bleeding 13. Parkinsons Disease 14. LGIB secondary to rectal ulcer:[Date range (3) 96242] with rectal ulcer s/p sigmoidoscopy and cauterization. 15. stage III chronic kidney disease 16. Melanoma, s/p removal Social History: Lives in [Hospital3 ] facility with the help of a caretaker, [Name (NI) 3065]. Smoked [1-22] ppdx for 30 years but quit 4-5 years ago, No ETOh although socially drank previously, denies illicit drug use. Next of [Doctor First Name ] -- a [Doctor First Name ] [Name (NI) ] [Name (NI) 96244]. Family History: not relavent to the current admission Physical Exam: Exam on arrival to the hospital: GEN: Lethargic, NAD, responds to commands but difficult to rouse. Intermittent tremor HEENT: EOMI, PERRL, MMM, crusting on eyelids BL, difficult to view oropharynx due to nonrebreather mask. NECK: JVD to 2 cm below jawline sitting at 45 degrees, no Cervical LAD, no bruits. Mild neck stiffness, COR: irregularly irregular rate and rhythm. 2/6 systolic murmur heard best at apex c/o radiation. Difficult to hear due to breath sounds. Occasional Vtach during exam PULM: Diffuse wheezes, diffuse rhonchi, some crackles BL at bases. ABD: Soft, NT, mildly distended, +BS, no HSM, no masses. Gen: Gross hematuria in catheter EXT: 1+ pitting edema BL to level of mid calf. R>L. Good DP pulses. No erythema. WWP. NEURO: alert, oriented to person, place, not time. Generally cooperative. CN II ?????? XII grossly intact. Strengh grossly in tact in upper extremity. ? sensation below the ankle BL. Difficult to move LE due to pain. No cerebellar dysfunction. Cogwheeling rigidity in UE BL on passive movement. SKIN: diffuse dry skin. 6cm diameter open deep erythematous ulcer on R heal. Superficial ulcer with overlying dusky skin on L heal. Pertinent Results: ADMISSION LABORATORY STUDIES: - [2139-1-1] 02:20PM WBC-8.8 (NEUTS-83.0* LYMPHS-9.3* MONOS-5.7 EOS-1.7 BASOS-0.3) RBC-2.55* HGB-7.6* HCT-24.0* MCV-94# MCH-29.8 MCHC-31.6 RDW-15.1 PLT COUNT-248 - [2139-1-1] 02:20PM [2139-1-1] 02:20PM PT-14.9* PTT-30.0 INR(PT)-1.3* - [2139-1-1] 02:20PM GLUCOSE-88 UREA N-35* CREAT-2.3* SODIUM-141 POTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-28 ANION GAP-12 ALT(SGPT)-7 AST(SGOT)-24 ALK PHOS-53 TOT BILI-0.2 LIPASE-28 cTropnT-0.10* CK-MB-8 proBNP-5173* - [2139-1-1] 02:20PM URINE COLOR-Red APPEAR-Cloudy SP [Last Name (un) 155]-1.013 [2139-1-1] 02:20PM URINE BLOOD-LG NITRITE-NEG PROTEIN-150 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM URINE RBC->50 WBC-[11-8]* BACTERIA-MOD YEAST-NONE EPI-0 - [2139-1-1] 02:58PM TYPE-ART RATES-21/ TIDAL VOL-355 O2-40 PO2-91 PCO2-46* PH-7.40 TOTAL CO2-30 BASE XS-2 INTUBATED-NOT INTUBA VENT-SPONTANEOU [2139-1-1] 02:27PM freeCa-1.12 DISCHARGE LABORATORY STUDIES: Na 139, K 4.7, Cl 104, Bicarb 30, BUN 38, Cr 1.9, Glucose 89 Calcium 8.2, Mg 2.2, Phos 3.8 WBC 9.7, HCT 28.4, PLT 193 MICROBIOLOGY: - [2139-1-3] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST: NEGATIVE - [2139-1-2] URINE Legionella Urinary Antigen: NEGATIVE - [2139-1-2] RIGHT HEEL SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL {PROTEUS MIRABILIS, CORYNEBACTERIUM SPECIES (DIPHTHEROIDS)}; ANAEROBIC CULTURE-FINAL INPATIENT PROTEUS MIRABILIS \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- 8 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 4 S TRIMETHOPRIM/SULFA---- =>16 R - [2139-1-1] URINE URINE CULTURE-FINAL {YEAST} INPATIENT - [2139-1-1] BLOOD CULTURE WITH NO GROWTH [2139-1-11] 3:55 pm BLOOD CULTURE Blood Culture, Routine (Pending): x 2 Urine Cytology [2139-1-4]: SUSPICIOUS FOR UROTHELIAL CARCINOMA. RADIOLOGY: - [2139-1-1] SEMI-UPRIGHT AP VIEW OF THE CHEST: IMPRESSION: Patchy opacities in both lung bases, which may reflect atelectasis but infection cannot be excluded. Probable trace left pleural effusion - [2139-1-2] ECHO: The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion - [2139-1-2] RENAL US: Multiple bilateral renal cysts. No hydronephrosis. Further characterization of the kidneys is limited by poor visualization - [2139-1-3] RIGHT FOOT FILM: Three views. Visualized cortical margins are intact. Bony mineralization appears ormal. There are mild degenerative arthritic changes in the first metatarsophalangeal joint. A small calcaneal spur is present. There is scattered atherosclerotic calcification. A shallow ulcer is noted in the soft tissue overlying the posterior aspect of the calcaneus. There is underlying soft tissue swelling. IMPRESSION: No definite evidence of osteomyelitis. [2139-1-11] CXR :As compared to the previous radiograph, the right medial lung base shows an area of increased density, consisting of peribronchial opacities associated with air bronchograms. In the appropriate clinical setting, the findings would be consistent with aspiration pneumonia. Otherwise, the radiograph is unchanged. Borderline size of the cardiac silhouette without pulmonary edema. Left pectoral pacemaker, right PICC line. No pleural effusions. Brief Hospital Course: COPD Exacerbation/Hosp Acquired PNA: Pt was in hypercarbic respiratory failure upon presentation to ED and was admitted to the ICU on non-invasive ventilation. He was treated with steroids, nebs and weaned from non-invasive prior to transfer to floor. Pt was continued on steroid taper and was initially improving. However, he was noted to have worsening cough with sputum production, rising WBC ct and new infiltrate consistent with a diagnosis of HAP. He was started on a course of Vanc/Zosyn (day 1 was [2139-1-11] of a planned 8 day course). Please recheck Vancomycin level on Thursday prior to vancomycin dose (has been dosed at 8 p.m.) as she was initially on 1g q48hrs, this was switched to 1g q24hrs on [1-12] given a vanc level of 8.1 on [1-12]. Goal Level 15-20. Hematuria/UTI/Bladder Carcinoma: Pt with a 5 year hx of high grade bladder cancer who was referred in from his facility for worsening anemia due to chronic hematuria. Pt was being treated with augmentin for a UTI and received a dose of gentamycin prior to admission to [Hospital1 18]. Given his hx of MDR organisms, he was treated with zosyn for a 10 day course. Urology was consulted for chronic hematuria and cytology returned suspicious for bladder carcinoma. HCP and patient were notified and pt is scheduled to f/u with urology later this week. Pt was transfused by slowly drifting hematocrit and will need close f/u with urology (1 unit PRBC on [1-2] and 1 unit PRBC on [1-8]). Clostridium difficile: At the time of admission, pt was taking a po vanco taper for a episode of Cdiff in [Month (only) 1096]. Pt was started on Vanco 125mg QID while on broad spectrum abx with plan to taper after completed of course for HAP. Stage III CKD: Pt was in acute renal failure on admission which improved after IVF and was restarted on home lasix regimen with stable creatinine. Creatine did increase from 1.5 ([1-12]) to 1.9 ([1-13]) without a change in hemodynamics and without a change in volume status (euvolemic on exam), this will need to be rechecked. His Cr was 1.9 on discharge (which is within his baseline of 1.5-2.0), PLEASE RECHECK CREATININE ON THURSDAY [2139-1-15]- if increasing please discontinue lasix and dose based on weight prn gain > 3 pounds. Paroxysmal Afib- continued on amiodarone and beta blocker, pt is not on anticoagulation due to GI bleed Hypertension- continued on amlodipine Parkinson's disease- continued on Sinemet Bilateral heel ulcers: pt was found on admission to have pressure ulcers on both heals. The right side required a bedside debridement while the left was a dark blister that was treated with offloading and wound care. Pt will need continued offloading with multipodus boots and podiatry f/u. Health care proxy: [Month/Day/Year ] [Name (NI) ] [Name (NI) 96246]. Phone: [0-0-]. Cell: [0-0-]. CODE STATUS: confirmed DNR/DNI with HCP [Name (NI) ] Medications on Admission: amiodarone 200 mg daily Lasix 20 mg Tablet 3x / week metoprolol tartrate 25 mg 1.5 tablets TID simvastatin 10 mg Daily isosorbide mononitrate 30 mg Tablet Sustained Release Daily amlodipine 10 mg daily acetaminophen 650 mg Q6H PRN allopurinol 100 mg QOD DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution PRN albuterol Q6H PRN omeprazole 20 mg daily mirtazapine 15 mg QHS carbidopa-levodopa 25-100 mg TID Ferrous sulfate 325 mg daily bisacodyl 10mg rectally daily PRN Fleet enema rectally daily PRN docusate sodium 100 mg [Hospital1 ] PRN senna 8.6 mg [Hospital1 ] PRN oxycodone 5mg [Hospital1 ] PRN for pain multivitamin daily Augmentin 500mg TID x 7 days start [12-29] Discharge Medications: 1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. furosemide 20 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 3. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain. 8. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 9. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) Inhalation every six (6) hours. 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for pain. 18. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). 19. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for L leg pain. 20. piperacillin-tazobactam 2.25 gram Recon Soln Sig: 2.25 g Intravenous Q8H (every 8 hours) for 7 days. 21. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q48H (every 48 hours) for 7 days. Discharge Disposition: Extended Care Facility: [Hospital ] LivingCenter - Heathwood - [Location (un) 55] Discharge Diagnosis: Hematuria Acute blood loss anemia. COPD exacerbation Hospital Acquired Pneumonia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [Known lastname 64579], You were sent to the hospital for a blood transfusion and noted to have shortness of breath and a likely urinary tract infection. You started to improve with treatment for a COPD exacerbation but later developped a pneumonia. You have been treated with antibiotics for the urinary tract infection and the pneumonia. You were transfused for the low blood counts but you continue to have blood loss in your urine. You had a sample of urine sent that is concerning for recurrence of the bladder cancer and you will need to follow up with Dr. [Last Name (STitle) 770]. We made the following changes to your medications: - continue taking Vancomycin & Zosyn for another X days - stop Augmentin Followup Instructions: Department: SURGICAL SPECIALTIES When: THURSDAY [2139-1-15] at 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4653], MD [Telephone/Fax (1) 5727] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Name:[Doctor Last Name ] S.[Name8 (MD) ],MD Address: [Street Address(2) ], 2 WEST, [Location (un) ],[Numeric Identifier 809] Phone: [Telephone/Fax (1) 14148] Please call the above number for a follow up appointment to your hospitalization with hte next two weeks	[ "599.70", "780.09", "V45.01", "188.9", "427.31", "V10.82", "V10.46", "486", "585.3", "599.0", "V12.54", "707.25", "332.0", "403.90", "V58.61", "285.1", "491.21", "518.81", "584.9", "707.07" ]	icd9cm	[ [ [] ] ]	[ "86.28", "38.97" ]	icd9pcs	[ [ [] ] ]	14417, 14509	8709, 11660	270, 277	14634, 14634	4278, 6322	15567, 16160	3027, 3066		12392, 14394		14530, 14613		11686, 12369			14809, 15441									3081, 4259												6357, 8686						15470, 15544						211, 232										305, 1800											14649, 14785				1822, 2674	2690, 3011
44,222	192,189	48350	Discharge summary	report	Admission Date: [2180-7-19] Discharge Date: [2180-7-20] Date of Birth: [2107-6-27] Sex: M Service: MEDICINE Allergies: Corgard / Lasix Attending:[First Name3 (LF) 1711] Chief Complaint: Bradycardia Major Surgical or Invasive Procedure: none History of Present Illness: 73M with CAD s/p DES to RCA and LCX, DMII, hyperlipidemia, LVH, called EMS early this morning reporting two days of lethargy and lightheadedness. On arrival EMS found him to have a neart rate in the 30's. . The patient was recently started on atenolol 25mg two days ago for treatment of CAD and frequent atrial and ventricular ectopy. He was also told to decrease his diltiazem dosing. He took his first dose of atenolol Monday, without decreasing his diltiazem. He reports feeling normal and active during the day Monday and feeling weak and lightheaded monday night. He took his second dose Tuesday morning and reports feeling fine all day tuesday as well. Tuesday night he reports feeling weak, lightheaded, and almost fell. He went to bed and then decided to call EMS at 4am to bring him in to the ED. . On arrival to the ED he was in a regular junctional rhythm without P waves at a rate of 34 and systolic blood pressure of 106. His Oxygen saturation was 100% RA. He was given Glucagon 5mg and Magnesium. His heart rate remained between 22 and 59, mostly in 30's, during his stay in the ED and his blood pressure ranged 84-121/43-60, mostly 100/50. He was given .5mg of atropine when his HR dipped to 22 and blood pressure decreased to 85. Heart rate responded to 33 with blood pressure 105/57. The first set of cardiac enzymes were negative. Also with new acute renal failure with creatiinne of 1.7 from baseline 1.2. . The patient underwent holter monitoring on [7-3] for evaluation of non-sustained VT. This evaluation showed sinus bradycardia with episodes of junctional bradycardia with rates as low as 39. It also showed an asymptomatic daytime pause of 3.3 seconds and frequent atrial and ventricular ectopy. . He also reports a syncopal episode in [Month (only) 404]. He was evaluated by Neurology and this was attributed to hypoglycemia or parkinson's. . On arrival to the CCU he had a rate of 32 with blood pressure 100/60. He was given 1mg of calcium chloride with increased heart rate to 56 and increased blood pressure to 150/80. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . He sleeps on one pillow and has no PND, peripheral edema, weight gain, syncope, or claudication. He occasionally experiences postural lightheadedness when standing up from a seated position. Past Medical History: 1. CAD, status post stening x3, 1 drug-eluting, 2 non. He was followed by a cardiologist at [Hospital6 1708]. 2. Diabetes mellitus with diabetic neuropathy. 3. Dyslipidemia including hypertriglyceridemia. 4. Hypertension. 5. A history of multiple squamous skin cancers. 6. Proteinuria Social History: He is single and lives alone. He is a retired [Location (un) 511] telephone worker. He has remote history of smoking cigars, quit [2170] after 40 years of smoking, never smoked cigarettes. Drinks 1.75L whiskey a month. Family History: Father - died MI in 50s Mother - died of cancer at age 88 Brother - DM, Parkinsons Physical Exam: GENERAL: WDWN male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no JVP. CARDIAC: Bradycardic. normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: CTAB, Bronchial breath sounds. ABDOMEN: Obese, Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP and PT dopplerable Left: DP and PT dopplerable Pertinent Results: EKG: [7-19]- Junctional bradycardia. Compared to the previous tracing of [2180-7-19] right bundle-branch block is no longer recorded. The Q-T interval is prolonged . [2180-7-19] 05:15AM BLOOD WBC-9.9 RBC-4.05* Hgb-13.1* Hct-39.0* MCV-96 MCH- 32.4* MCHC-33.6 RDW-14.5 Plt Ct-245 [2180-7-20] 05:00AM BLOOD WBC-9.3 RBC-3.99* Hgb-12.9* Hct-37.8* MCV-95 MCH-32.4* MCHC-34.1 RDW-14.3 Plt Ct-197 [2180-7-19] 05:15AM BLOOD Neuts-59.0 Lymphs-32.5 Monos-5.1 Eos-2.9 Baso-0.5 [2180-7-19] 05:15AM BLOOD PT-13.2 PTT-24.5 INR(PT)-1.1 [2180-7-19] 05:15AM BLOOD Plt Ct-245 [2180-7-20] 05:00AM BLOOD Plt Ct-197 [2180-7-19] 05:15AM BLOOD Glucose-268* UreaN-21* Creat-1.7* Na-132* K-5.0 Cl-100 HCO3-22 AnGap-15 [2180-7-19] 03:15PM BLOOD Glucose-118* UreaN-24* Creat-1.7* Na-135 K-4.5 Cl-101 HCO3-26 AnGap-13 [2180-7-20] 05:00AM BLOOD Glucose-56* UreaN-22* Creat-1.2 Na-135 K-4.2 Cl-101 HCO3-27 AnGap-11 [2180-7-19] 05:15AM BLOOD CK(CPK)-52 [2180-7-19] 03:15PM BLOOD CK(CPK)-39 [2180-7-19] 05:15AM BLOOD cTropnT-0.01 [2180-7-19] 03:15PM BLOOD CK-MB-4 cTropnT-<0.01 Brief Hospital Course: 73 year old man with CAD, DMII, parkinson's disease, found to have junctional bradycardia after recent initiation of atenolol, likely sick sinus syndrome, in NSR after calcium chloride administration. . # Bradycardia: presented with junctional rhythm with HR in 30s, then in NSR with HR in 60s-70s with 1 amp calcium chloride administration. It is thought that the recent addition of atenolol to his home diltiazem regimen may have caused suppression of AV node, with retrograde p waves causing a simulated pacemeaker syndrome, when the atria and ventricle contract simultaneously, causing increased vagal tone. After the calcium chloride administration, patient maintained HR in 60s-70s, with BP 150s-160s. He was kept off atenolol (and all beta blockers). He was kept off diltiazem (and all calcium channel blockers). He is to not resume these classes of medicines. It was reviewed with patient that he likely has sick sinus syndrome, for which he can only take diuretics/ACEi/ARBs for blood pressure control. He was discharged home with [Doctor Last Name ] of Hearts monitor and outpatient workup for sick sinus syndrome. Dr. [Last Name (STitle) ] will be getting the results of the [Doctor Last Name ] of Hearts monitor and will discuss them with patient on [2180-8-9]. . # Acute on chronic Renal failure: Cr on presentation 1.7, which improved to baseline 1.2. Likely from poor cardiac output. Patient's UOP was within normal limits on discharge. . # Diabetes II: metformin and glyburide were held. Patient continued on home dose insulin and insulin sliding scale. . # Hypertension: beta blockers and calcium channel blockers were held. SBP range was 150s-160s. Outpatient management will be primarily ARBs, diuretics. He is to continue valsartan and hydrochlorothiazide (12.5 mg daily) as his new BP meds. . # Coronary Artery Disease: s/p two DES to RCA and LCX in [2173]. Patient was continued on aspirin 81mg and atorvastatin 10 mg. He will be off BB and CCB due to likely sick sinus, as noted above. . # Peripheral Neuropathy: from diabetes. Continued on home dose gabapentin. . # Spinal stenosis: pain control was adequate throughout hospitalization. . # Parkinson's disease ?????? stable. Cont carbidopa-levodopa. Medications on Admission: Atenolol 25 mg Tablet 1 Tablet(s) by mouth once a day Atorvastatin [Lipitor] 10 mg Tablet 1 Tablet(s) by mouth twice daily Carbidopa-Levodopa [Sinemet] 10 mg-100 mg Tablet 1 Tablet(s) by mouth four times a day Diltiazem HCl 180 mg Capsule, Sustained Release 1 Capsule(s) by mouth every day Gabapentin 300 mg Capsule [12-3] Capsule(s) by mouth Once or twice daily [2180-5-3] Glyburide 5 mg Tablet Two Tablet(s) by mouth am nr LO DOSE INSULIN SYRINGES 1CC AS DIRECTED FOR INSULIN ADMINISTRATION Metformin [Glucophage XR] 500 mg Tablet Sustained Release 24 hr three Tablet(s) by mouth daily Valsartan [Diovan] 160 mg Tablet One Tablet(s) by mouth Daily Aspirin [Ecotrin Low Strength] 81 mg Tablet, Delayed Release (E.C.) one Tablet(s) by mouth daily Blood Sugar Diagnostic [Accu-Chek Aviva] Strip Two Daily Insulin NPH Human Recomb [Humulin N] 100 unit/mL Suspension inject subcutaneously 60units in the morning Multivitamin Discharge Medications: 1. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:2 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Carbidopa-Levodopa 10-100 mg Tablet Sig: One (1) Tablet PO four times a day. 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Sixty (60) units Subcutaneous once a day. 9. Glucophage XR 500 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. 10. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO once a day. 11. Outpatient Lab Work chem 7 on [2180-7-26]. Call results to Dr. [First Name (STitle) 216] at [Telephone/Fax (1) 250] Discharge Disposition: Home Discharge Diagnosis: PRIMARY: 1. Bradycardia with junctional rhythm, medication induced 2. Sick sinus syndrome 3. Acute on Chronic Kidney disease, stage 3 4. Diabetes Mellitus Type 2 5. Hypertension 6. Coronary Artery Disease Discharge Condition: stable, with HR 70-80, SBP 150-160 Discharge Instructions: You were admitted to the hospital with slow heart rate (bradycardia) likely related to your atenolol and diltiazem medications. You were given calcium chloride which increased your heart rate into normal sinus rhythm. You are to not take atenolol (or other beta blockers). You are to not take diltiazem (or other calcium channel blockers). For blood pressure control, you will take your valsartan (your home dose) and be started on a medicine which does not affect heart rate (hydrochlorothiazide). You will be wearing [Initials (NamePattern4) ] [Last Name (NamePattern4) ] of Hearts Monitor after you go home. Please follow instructions for use, Dr. [Last Name (STitle) ] will be getting the results and will discuss them with you on [2180-8-9]. . NEW MEDICATION: -hydrochlorothiazide 12.5 mg daily . Please seek medical attention for lightheadedness, weakness, fatigue, chest pain, palpitations, shortness of breath, fevers, abdominal pain, or any other concerns. Followup Instructions: Cardiology: Provider: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Name (STitle) ] Phone: [Telephone/Fax (1) 62] Date/Time:[2180-8-9] 9:00 Primary Care: Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2180-8-28] 8:30 Nephrology: Provider: [First Name11 (Name Pattern1) 1877] [Last Name (NamePattern1) 1878], M.D. Phone:[Telephone/Fax (1) 721] Date/Time:[2180-11-2] 1:00 Dermatology: Provider: [Name10 (NameIs) 28909],[Name11 (NameIs) 8754] DERMATOLOGY GEN-[Doctor First Name 8754] (NHB) Date/Time:[2180-8-4] 8:15 Completed by:[2180-7-21]	[ "403.90", "584.9", "357.2", "414.01", "427.81", "585.3", "724.00", "332.0", "272.4", "250.60", "E942.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	9563, 9569	5313, 7570	288, 294	9818, 9855	4184, 5290	10885, 11552	3515, 3599		8560, 9540		9590, 9797		7596, 8537			9879, 10862									3614, 4165																								237, 250										322, 2941															2963, 3254	3270, 3499
19,409	154,044	30966	Discharge summary	report	Admission Date: [2164-4-30] Discharge Date: [2164-5-16] Date of Birth: [2092-9-28] Sex: F Service: SURGERY Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 4748] Chief Complaint: ischemic left foot Major Surgical or Invasive Procedure: diagnositic arteriogram [5-1] left SFA-AT bpg with insitu saphenous vein [2164-5-7] History of Present Illness: -71y/o female initally evaluated ([4-29] ) at [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Hospital for left foot ischemia which became progressive over several days prior to admission with foot pain with walking. No resat pain.workup included foot film whic was negative for osteomylitis or fracture. She was placed on leviquin for mild left heel erythemia. u/s of extremity negative for DVT.there was an acute change in pulse exam and foot color and temperature with increasing pain at rest.Patien was began on heparin and transfered to [Hospital1 8482] under the care of Dr. [Last Name (STitle) 1391] for further evaluaton and treatment on [2164-5-1] Past Medical History: history of Dm2 history of chronic renal failure history of atrial fibrillation history of hypertension history of coronary artery disease with ischemic cardiomyopathy and systoic CHF history of gout history of DVt history of chronic venous stasis ulcerations history of osteoarthritis, degenerative s/p bilateral THR and rt. TKR history of depression history of hypercholestremia Social History: married lives with spouse former tobacco user rare ETOH use Family History: unknown Physical Exam: VITAL SIGNS: 98.9-84-18 134/72 )2 sat 95%@2L/NC GEN:oriented x3 HEENT: no LAD HEART: RRR no mumur, gallop or rub Lungs: clear to auscultation ABD: obese, soft nontender PV:paalpable femorals bilaterally, dopperable pedal pulses rt. absetn pedal pulses left with cool, dusky foot which extends to mid calf. Neuro: nonfocal Pertinent Results: [2164-4-30] 05:59PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.016 [2164-4-30] 05:59PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2164-4-30] 05:59PM URINE RBC-0-2 WBC-[5-27] BACTERIA-FEW YEAST-NONE EPI-0-2 [2164-4-30] 05:59PM URINE HYALINE-0-2 [2164-4-30] 05:59PM URINE AMORPH-MOD [2164-4-30] 05:05PM GLUCOSE-193* UREA N-34* CREAT-1.9* SODIUM-137 POTASSIUM-5.3* CHLORIDE-103 TOTAL CO2-26 ANION GAP-13 [2164-4-30] 05:05PM estGFR-Using this [2164-4-30] 05:05PM CK(CPK)-74 [2164-4-30] 05:05PM CALCIUM-9.1 PHOSPHATE-4.7* MAGNESIUM-2.2 [2164-4-30] 05:05PM %HbA1c-6.8* [2164-4-30] 05:05PM WBC-9.7 RBC-4.74 HGB-13.7 HCT-42.0 MCV-89 MCH-29.0 MCHC-32.7 RDW-16.3* [2164-4-30] 05:05PM PLT COUNT-276 [2164-4-30] 05:05PM PT-13.2* PTT-28.9 INR(PT)-1.2* Brief Hospital Course: [5-1] admitted.Diagnostic angio which demonstrated occluded SFA and [Doctor Last Name ]. Iv heparin continued. CK's monitered. [5-2] admitting creatinine 1.9, post angio creatinine 3.1. Renal consulted.B/P parameters liberalized, IV hydration continued with NAHCO3 and planned surgery defered. C3C4 normal.IV heparin continued. [5-3] slow improvement of renal function. placed on low K diet. [5-5] continued improvment in renal function cr.2.4 [2164-5-8] DOS: left fme-disatal AT with insitu SVGbpg. Transfered to PACU stable with dopperable left DP pulse. Transfered to ICU for inotropic support.Dobutamine weaned overnight. Patient transfered to VICU [5-9] IV heparin discontinued.. [2082-5-10] Patient's PCA converted to oral analgesics. Swan continued coumadin reinstuted for history of AF. Swan converted to CVL. ambulation began and PT consulted. JP drain discontinued. [2086-5-12] agressive pulmonary care. Transfered to regular nursing floor. required diamox for diursing. Lasix reinstuted. patient encouraged to work with physical thearphy.CVL discontinued. Foley discontinued. [5-16] Patient screenedand accepted to rehab. Transfered to rehab for less 30 day stay. Medications on Admission: meds added @ d/c to preadmit: bisacodyl 10 mgm qd prn dextromethorphan-guaifenesin 10/100mgm /5ml 5-10ml q6h prn albuterol inhallation q6h prn ipratropium bromide inhallation q6hprn hydromorphone 2 mgm q3-4 hprn percocet 5/325mgm q4-6h prn pain Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 13. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: [4-26] MLs PO Q6H (every 6 hours) as needed. 14. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 15. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 16. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every 3 to 4 Hours) as needed. 17. Acetazolamide 250 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12 hours). 18. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 20. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: as directed Subcutaneous twice a day: NPH 50 units @ breakfast NPH 40 units @ dinner. 21. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection four times a day: AC: glucoses <150 no insulin glucoses 151-200/2u glucoses 201-250/4u glucoses 251-300/6u glucoses 301-350/8u glucoses 351-400/10u glucoses >400 [Name8 (MD) 138] Md HS: glucoses < 250 no insulin glucoses 251-300/2u glucoses 301-350/4u glucoses 351-400/6u glucoses > 400 [Name8 (MD) 138] Md u=units. Discharge Disposition: Extended Care Facility: [Hospital3 2857] - Maplewood - [Location (un) 32944] Discharge Diagnosis: ischemic left foot history of DVT history of atrial fibrillation history of hypertension history of coronary artery disease,ischemic cardiomyopathy,systolic / diastolic dysfunction ,CHF history of gout history of osteoarthritis, degenerative ,s/p rt. TKR history of chronic venous stasis ulcerations history of morbid obesity history of gall bladder disease s/p CCy history of DM2, uncontrolled history of depression history of hypercholestremia postangio contrast induced ATN, resolved postop blood loss anemia, transfused postoperative hypotension secondary to cardiomyopathy and systollic/diastoic dysfucntion requiring inotrops, improved. Discharge Condition: stable Discharge Instructions: patient may shower no tub baths ambulate essential distance ful weight bearing with ace wrap to left foot to knee elevate left foot and leg when sitting in chair continue all medications as directed continue a stool softner wqhile on pain medication call if you develope a fever >101.5 call if you develop redness, drainage or groin sewlling at your surgical wounds Followup Instructions: 2 weeks. Dr. [Last Name (STitle) 1391] call for appointment [Telephone/Fax (1) 1393] Completed by:[2164-5-16]	[ "440.20", "414.01", "V12.51", "585.9", "V58.61", "414.8", "250.02", "584.9", "403.90", "428.0", "428.40" ]	icd9cm	[ [ [] ] ]	[ "39.29", "88.42", "38.93", "88.48" ]	icd9pcs	[ [ [] ] ]	6685, 6772	2917, 4133	313, 407	7459, 7468	1992, 2894	7883, 8007	1625, 1634		4428, 6662		6793, 7438		4159, 4405			7492, 7860									1649, 1973																								255, 275										435, 1128															1150, 1532	1548, 1609
27,800	117,045	46359	Discharge summary	report	Admission Date: [2161-7-15] Discharge Date: [2161-7-30] Date of Birth: [2096-5-9] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2474] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Intubation Re-intubation History of Present Illness: 65 YO M with severe COPD, schizophrenia, pulmonary hypertension who presented to [Hospital1 18] with worsening cough, dyspnea, and hypoxia over the last 3 days. VNA found pt to be hypoxic and with sats in 70's. EMS was called and noted him to be cyanotic. His O2 improved to 80's with oxygen. . Upon presentation the the ED, his VS were: 97.6 72 131/79 18 98% on NRB. He was taken off the NRB and placed on 4L NC due to some agitation/discomfort. While on 4L NC, he became somnolent and was placed on BiPap at which time an ABG was 7.23/93/113. He was therefore intubated with succ and etomidate with a 7.5 ETT tube, 25 at the lip. He was sedated with propofol and given solumedrol, nebs, and levofloxacin 750mg IV. An EKG showed TWI in V3-V5 with first troponin of 0.01. CXR showed a possible RML PNA. He is being admitted to the MICU for further treatment of his hypercarbic respiratory failure. Just prior to transfer his BP was noted to be 93/64 despite 2L NS bolus. Given his hypotension, his propofol was changed to versed and fentanyl. . Of note, he has been admitted to the ICU multiple times for COPD exacerbations over the past year. During his most recent hospitalization, a CXR showed right basilar infiltrate and possible retro-cardiac infiltrate. . Upon arrival to the floor, he is intubated and sedated. He is unable to provide any additional history or ROS. Past Medical History: 1) COPD: FEV1 23% predicted, home 1.5-2L O2 at night only 2) Secondary Pulmonary Hypertension (51-66 mm Hg on ECHO [2159-9-18]) 3) Schizophrenia 4) Hx GI bleeding 5) Mental Retardation 6) Pulmonary Hypertension 7) s/p tonsillectomy Social History: Lives in [Location ] with brother and brother-in-law. On disability since [2149] for mental health issues. Has home nurse visit every morning and evening. Reports ~50 pack-year smoking and has now cut down to 3 cigs/day. Denies any ETOH/drug use. Family History: Patient unable to provide. Physical Exam: Vitals: T:97.2 BP:120/74 P:69 R:22 SaO2:100% on 2L General: Caucasian Male laying down in bed in NARD. [Year (4 digits) 4459]: EOMI, MMM, sclera anicteric Pulmonary: Diminished BS noted diffusely Cardiac: RR, distant S1 S2, no murmurs, rubs or gallops appreciated Abdomen: Appears distended (baseline per pt), soft, NT, normoactive bowel sounds Extremities: No edema Neurologic: Alert, oriented x 3. Able to relate history without difficulty. Cranial nerves II-XII intact. Normal bulk, strength and tone throughout. Pertinent Results: ================== ADMISSION LABS ================== [2161-7-15] 08:36AM BLOOD WBC-8.8 RBC-4.80 Hgb-15.0 Hct-45.3 MCV-94 MCH-31.2 MCHC-33.1 RDW-14.0 Plt Ct-253 [2161-7-15] 08:36AM BLOOD Neuts-72.0* Lymphs-22.4 Monos-3.4 Eos-1.9 Baso-0.3 [2161-7-15] 08:36AM BLOOD Glucose-123* UreaN-25* Creat-0.9 Na-145 K-4.6 Cl-104 HCO3-36* AnGap-10 [2161-7-15] 02:50PM BLOOD CK(CPK)-43* [2161-7-15] 02:50PM BLOOD CK-MB-2 cTropnT-<0.01 [2161-7-15] 08:36AM BLOOD Calcium-8.8 Phos-4.0 Mg-1.8 [2161-7-15] 08:36AM BLOOD Lactate-0.7 ================== DISCHARGE LABS ================== [2161-7-29] 07:30AM BLOOD WBC-14.0* RBC-4.34* Hgb-13.3* Hct-40.3 MCV-93 MCH-30.5 MCHC-32.9 RDW-13.4 Plt Ct-330 [2161-7-29] 07:30AM BLOOD Neuts-76.2* Lymphs-19.0 Monos-2.9 Eos-1.4 Baso-0.4 [2161-7-29] 07:30AM BLOOD Glucose-73 UreaN-30* Creat-1.1 Na-134 K-4.2 Cl-97 HCO3-29 AnGap-12 [2161-7-29] 07:30AM BLOOD ALT-48* AST-24 AlkPhos-53 TotBili-0.3 [2161-7-29] 07:30AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.9 ============ IMAGING ============ CTA CHEST ([2161-7-15] 4:15 PM) IMPRESSION: 1. No acute pulmonary embolism or thoracic aortic pathology detected. 2. Unchanged severe emphysema. 3. Linear subpleural consolidation in the right upper lobe and linear opacity in the left upper lobe, likely represent atelectasis. However, superimposed infection cannot be ruled out. 4. Multiple mediastinal lymph nodes, with cystic right hilar lymph nodes, have not enlarged since prior study. 5. Multiple pulmonary nodules in both lungs. The left lower lobe pulmonary nodules are slightly more conspicuous since the prior study of [2160-11-6]. A followup chest CT in three months is recommended for further evaluation of the same. 6. Right heart strain, likely secondary to the lung disease. CHEST X-RAY [7-27] FINDINGS: Hyperinflated lung, in keeping with known history of COPD. There is interval removal of feeding tube, and endotracheal tube. Interval improvement in aeration at the lung bases, with minimal atelectasis at the right lung base. Hilar, mediastinal, and cardiac silhouette stable. IMPRESSION: 1. No focal lung consolidation. 2. COPD. 3. No pleural effusion or pneumothorax. RENAL ULTRASOUND [7-28] FINDINGS: The right kidney measures 10.0 cm and the left kidney measures 10.5 cm. A tiny simple cyst is seen in the interpolar region of the right kidney measuring 1.0 x 0.7 x 0.9 cm. A simple cyst is seen at the medial portion of the lower pole of the left kidney measuring 5.2 x 4.5 x 4.0 cm. There is no hydronephrosis and no stone or solid mass is seen in either kidney. The pre-void bladder is moderately distended and unremarkable. The prostate is enlarged with a volume of 72 cc. IMPRESSION: 1. No hydronephrosis. 2. Simple bilateral renal cysts. 3. Enlarged prostate. Brief Hospital Course: 65 year old man with h/o COPD, pulm HTN, schizophrenia admitted with COPD exacerbation and respiratory failure, in improved condition. . # COPD Exacerbation: Pt presented to the ED after his VNA noted he was hypoxic to the 70s on his baseline O2 requirement of 2L NC at nightime. Work-up showed no PE but did show RUL conslidation. Patient was intubated on admission and had a prolonged and very complicated course, with difficulty in weaning off ventilator. Pt underwent a bronchoscopy given his difficulty weaning with cultures showing stenotrophomonas. After thorough discussions, patient was extubated and bridged with BIPAP as needed, however required re-intubation for hypercarbia and hypoxia. He was treated for HAP with Vanc/Cipro/Zosyn 8 day course. After multiple attempts at weaning sedation and poor progonsis, decision made to extubate on [7-23] and not to pursue re-intubation. Patient was able to maintain adequate ventilation and was transitioned to the medical floor. Patient was initially treated with high dose steroids, transitioned to oral prednisone with plan for slow taper by PCP upon outpatient [Name9 (PRE) ]. Patient placed on his home regimen of scheduled nebulizer treatments and pulmonary toilet. At time of discharge, O2 sats > 92% on 2L NC. . # Acute kidney injury: After diarrheal episode, Creatinine increased to 1.5 on [7-27], from 1.1 on [7-26] and baseline 0.7-0.8. After fluid resuscitation, creatinine improved to 1.1 on [2161-7-28]. Renal ultrasound [2161-7-28] shows simple cysts but no hydronephrosis. At time of discharge, renal function was at baseline. . # Tachycardia: Multifactorial in setting of critial illness, frequent b-agonists, volume depletion and alternating periods of sinus tachycardia and multifocal tachycardia. At time of discharge, patient with HR in 90's and in sinus rhythm. . # Positive blood culture: Pt has positive cultures from [7-19] which showed coag neg staph. Blood cultures have subsequently been negative suggesting contaminated sample. Although patient remained on linezolid, this was chosen for treatment of urinary infection and not bacteremia. . # VRE Urine: In setting of hypotension and positive urinalysis, found to have Vancomycin Resistant Enterococcus in urine culture from [7-19]. Pt completed 7 day course of Linezolid and is asymptomatic at time of discharge. . # GOALS OF CARE: Family meetings held throughout critical illness, and again once clinically improved. Primary care physician and health care proxy present during discussion, where patient re-iterated desire to remain full code. Also willing to undergo tracheotomy if necessary, although unclear of his long term wishes. Defer ongoing discussion to his primary care team. . # Schizophrenia: Stable, continued olanzapine. . # FEN/Lytes: Regular diet, replete lytes prn . # Prophylaxis: Heparin SC 5000 tid . # Code status: FULL CODE confirmed . # Dispo: Pending above . Medications on Admission: - Albuterol inhaler 2 puffs [Hospital1 ] and q4h PRN - Advair 250/50 2 puffs [Hospital1 ] - Home O2 1-2 L NC - Zyprexa 7.5mg daily - Spiriva 18 mcg daily - Tylenol PRN - Aspirin 81 mg daily - Docusate 100mg daily - Multivitain - Nicotine patch Discharge Medications: 1. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: Two (2) Tablet PO twice a day for 6 weeks. Disp:168 Tablet(s) Refills:0 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) for 7 days. Disp:qs qs Refills:0 6. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 1.5 Tablet, Rapid Dissolves PO DAILY (Daily). 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:2 8. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 9. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) inh Inhalation once a day. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [2-7] puff Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 12. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) patch Transdermal once a day. Discharge Disposition: Home With Service Facility: [Hospital ] Health Systems Discharge Diagnosis: Primary diagnoses: 1. COPD exacerbation 2. Community acquired pneumonia - stenotrophomonas 3. Respiratory failure 4. Bacteremia - gram positive cocci 5. Urinary tract infection - vancomycin resistant enterococcus 6. Pulmonary hyptertension . Secondary diagnoses 6. Schizophrenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 79627], You were admitted to the hospital for cough, trouble breathing and low oxygen levels due to a flare of your COPD and pneumonia. You were intubated twice for respiratory failure and given antibiotics, steroids and nebulizers. We have started you on two courses of antibiotics to treat bacteria we found in your lungs, urine and blood. Additionally, due to the injury to your lungs you will need to go to pulmonary rehab to improve your breathing. We are also very pleased to hear that you have cut back on your smoking and are confident that with the use of a nicotine patch you will be able to quit completely. Quitting smoking is one of the best measures you can take to prevent further decline in your lung function. . We have made the following changes to your medication list: 1. Please START Bactrim 2 tabs twice per day until [9-10]. 2. Please START Prednisone 40mg, Dr [First Name (STitle) 1022] will adjust the dose in the future. . 3. Please START nicotine patch Followup Instructions: Please be aware of your following appointments at [Hospital1 18]: . Department: [Hospital3 249] When: THURSDAY [2161-8-6] at 12:20 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2477], M.D. [Telephone/Fax (1) 250] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Provider: [Known firstname ] [Last Name (NamePattern1) 722], DPM Phone:[Telephone/Fax (1) 543] Date/Time: [2161-10-6] 1:15 . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2477], M.D. Phone:[Telephone/Fax (1) 250] Date/Time: [2161-10-7] 1:00 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2477] MD, [MD Number(3) 2478]	[ "V09.80", "V46.2", "584.9", "295.90", "276.2", "319", "599.0", "482.83", "041.04", "416.8", "305.1", "493.22", "518.81" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.6", "96.72", "96.04", "38.91" ]	icd9pcs	[ [ [] ] ]	10256, 10317	5742, 8694	334, 360	10640, 10640	2902, 5719	11833, 12636	2317, 2345		8997, 10233		10338, 10619		8720, 8974			10791, 11810									2360, 2883																								275, 296										388, 1768											10655, 10767				1790, 2028	2044, 2301
12,717	191,254	10854+10855	Discharge summary	report+report	Admission Date: [2143-11-27] Discharge Date: [2143-12-6] Service: [Location (un) 259] - Medicine HISTORY OF PRESENT ILLNESS: The patient is a [Age over 90 ] year old male with past medical history significant for coronary artery disease, recent revision of left hip, who was admitted on [2143-11-27], for a three day history of nausea, associated coffee ground emesis, episode of dark tarry stools, decreased p.o. intake, and mild confusion. The patient was then brought to [Hospital1 1444] where in the Emergency Department he was found to have a hematocrit of 31.2; nasogastric lavage positive for coffee ground and did not clear after two liters. The patient remained hemodynamically stable while in the Emergency Department and was given three liters total of intravenous fluids. Gastroenterology consultation was called at this time. The patient was then taken to the Medical Intensive EGD was deferred at the request of the patient and family. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post myocardial infarction in [2123], status post coronary artery bypass graft in [2124]. Last echocardiogram revealed an ejection fraction of 55% and 4+ mitral regurgitation. 2. Status post left hip revision in [2143-11-12]. 3. Status post pacemaker placement. 4. Status post colectomy secondary to diverticulitis in [2130]. MEDICATIONS ON ADMISSION: 1. Multivitamin. 2. Digoxin 0.25 mg p.o. once daily. 3. Zantac 150 mg p.o. twice a day. 4. Theophylline 100 mg twice a day. 5. Niferex 150 mg p.o. three times a day. 6. Aspirin 325 mg p.o. twice a day since procedure for deep vein thrombosis prophylaxis. 7. Lisinopril 5 mg p.o. twice a day. 8. Propranolol 20 mg p.o. twice a day. ALLERGIES: Sulfa. SOCIAL HISTORY: The patient lives by himself in [Hospital3 5673] facility and was at [Hospital3 ] since his procedure in [Month (only) 1096]. Th patient has two sons who are involved in his medical care. PHYSICAL EXAMINATION: Generally, the patient is a pleasant elderly male in no acute distress. Vital signs revealed temperature 99.3, blood pressure 139/68, pulse 76, respiratory rate 17, oxygen saturation 100% on two liters nasal cannula. Head, eyes, ears, nose and throat examination - The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. The oropharynx is clear, dry mucous membranes. The neck is supple, 7.0 centimeter jugular venous pressure noted. Cardiac examination - S1 and S2, regular rate and rhythm, III/VI holosystolic murmur that is best heard at the left lower sternal border with radiation to the apex. Chest was notable for diffuse wheezes. Abdomen is soft, nontender, nondistended, positive bowel sounds, no hepatosplenomegaly. The patient as guaiac positive per Emergency Department. Extremities - no cyanosis, clubbing or edema. The extremities are warm and well perfused. Neurologically, the patient is grossly intact with no focal deficits and normal speech. LABORATORY DATA: On admission, hematocrit was 31.2. HOSPITAL COURSE: 1. Gastrointestinal bleed - The patient was brought to the Medical Intensive Care Unit where serial hematocrit levels were performed. Of note, on hospital day number one, the patient had a decrease in his hematocrit from 32.6 to 28.4. At this time, the patient was transfused one unit of packed red blood cells with an increase of hematocrit to 33.9. Gastroenterology consultation service was called the following morning where there were preparations for emergent esophagogastroduodenoscopy. However, the patient's family deferred an esophagogastroduodenoscopy as well as upper gastrointestinal series at this time. The patient was continued on Protonix twice a day and all anticoagulation was held. Given the patient's appropriate response to the red blood cell transfusion, stable hemodynamics and deferment of esophagogastroduodenoscopy, the patient was transferred to the medical floor for further management. On hospital day number two, the patient agreed to an upper gastrointestinal series to evaluate for possible sources or bleeding noninvasively. Upper gastrointestinal series at that time was negative for any ulcers or tumors. Of note, there was mucosal prolapse into the duodenum of unclear significance. At the time of discharge, the patient will be continued on Protonix twice a day. Serial hematocrits from the time of transfer from Medical Intensive Care Unit until the time of discharge have remained stable. 2. Status post left hip revision - The patient clearly is at risk for deep vein thrombosis, however, given his history of gastrointestinal bleed, anticoagulation was held at this time. Two days prior to discharge (one week after admission), lovenox was started for DVT prophylaxis. 3. Coronary artery disease - The patient's has a known history of coronary artery disease. The patient's Aspirin was held throughout this hospital admission secondary to gastrointestinal bleed, and the patient's blood pressure medications were also held given low intravascular volume and to monitor. Digoxin was also discontinued. 4. Pulmonary - The patient has known history of pulmonary disease. Of note was wheezing on examination, and his Theophylline was restarted prior to discharge. 5. Prophylaxis - Given the patient's history of bleed in the setting of recent orthopedic surgery, the patient was placed on pneumonic boots and ambulation was encouraged. The patient also received influenza vaccine prior to discharge. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To [Hospital3 ]. MEDICATIONS ON DISCHARGE: 1. Protonix 40 mg p.o. twice a day. 2. Albuterol two puffs inhaled q6hours p.r.n. 3. Atrovent inhaler two puffs four times a day. 4. Theophylline 100 mg p.o. twice a day. 5. Lovenox 60 mg sq [Hospital1 ] until fully weight bearing 6. Captopril 25 mg po tid The patient is to remain on pneumonic boots overnight and he is being encouraged to ambulate frequently for deep vein thrombosis prophylaxis. He will follow-up with his PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 35372] [Telephone/Fax (1) 18735]. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 4446] Dictated By:[Last Name (NamePattern1) 7944] MEDQUIST36 D: [2143-12-1] 10:48 T: [2143-12-1] 12:44 JOB#: [Job Number 35373] Admission Date: [2143-11-27] Discharge Date: [2143-12-6] Service: ADDENDUM HOSPITAL COURSE: 1. Gastrointestinal bleed: Throughout the remainder of Mr. [Known lastname 35374] hospital stay, his hematocrit remained stable. On hospital day number seven, given the patient's high risk for deep venous thrombosis due to recent orthopaedic surgery and relative immobility since that time, the patient was started on Lovenox for deep venous thrombosis prophylaxis. The patient showed no signs of bleeding after starting the anticoagulation therapy, and his hematocrit remained stable, and there was no evidence of nausea, vomiting, or bright red blood per rectum. The patient's prophylactic anticoagulation will be continued until he is 2. Right shoulder pain: Patient complaining of right shoulder pain, and an x-ray revealed no fracture dislocation, with slight narrowing of subacromial space. No further imaging studies were performed in light of the patient's inability to have an MRI secondary to joint replacement and pacemaker. The patient should be followed by Physical Therapy at rehabilitation. 3. Congestive heart failure: The patient had mild congestive heart failure exacerbation secondary to fluid resuscitation in the setting of gastrointestinal bleed. The patient was diuresed with lasix, and showed no evidence of failure upon discharge. DISCHARGE DIAGNOSIS: 1. Upper gastrointestinal bleed 2. Status post hip revision 3. Congestive heart failure 4. Coronary artery disease DISCHARGE STATUS: To rehabilitation DISCHARGE CONDITION: Good DISCHARGE MEDICATIONS: 1. Protonix 40 mg by mouth twice a day 2. Theophylline 100 mg by mouth twice a day 3. Captopril 25 mg by mouth three times a day, which will be changed to Lisinopril at the time of discharge 4. Lovenox 60 mg subcutaneously every 12 hours 5. Albuterol inhaler as needed 6. Atrovent inhaler every six hours [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 4446] Dictated By:[Last Name (NamePattern1) 35375] MEDQUIST36 D: [2143-12-5] 23:50 T: [2143-12-6] 00:37 JOB#: [Job Number 35376]	[ "424.0", "V45.01", "V45.81", "578.0", "412", "428.0", "401.9", "496" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]				8079, 8085					8108, 8664		7899, 8057	5671, 6586	1419, 1779	6603, 7878																								2021, 3094																					149, 989															1011, 1393	1796, 1998	5597, 5645
40,822	102,495	3073	Discharge summary	report	Admission Date: [2103-7-9] Discharge Date: [2103-8-25] Date of Birth: [2054-6-24] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3918] Chief Complaint: S/p fall with altered mental status and fever Major Surgical or Invasive Procedure: Bone Marrow Biopsy Lumbar Puncture x2 Bronchioalveolar Lavage PICC line placement History of Present Illness: 49 yoM with h/o HIV and intermittent adherence to therapy (diag. in [2087], last CD4 on [2103-6-13] = 22 w/ VL 891,000, on intermittent HAART, last started on [2103-6-15]), EtOH abuse, anal HPV, and recent admission from [2103-6-12] - [2103-6-21] for malaise and weakness who was admitted [2103-7-9] for altered mental status and mechanical fall at home and was found to be pancytopenic. The patient had been recently discharged from rehab (where he had gone after the admission ending on [6-21]) to his home at the [Company 3596]. The patient reported that he was feeling well at rehab/home and did not have any specific complaints but on [7-9] he had a mechanical fall and was thought to be more confused by his home VNA so he was brought into the hospital. Denied head strike or head/back pain from fall, stated that he felt weak and just collapsed at 1pm. Denies any CP,sob, n/v. no f/c. Denies BRBRP or melena. History difficult to take due to his mental status, proxy contact attempted but no answer, left message to call back for ICU consent and further hx taking. Of note, during his earlier admission in [Month (only) ] for AMS, had an unremarkable LP and MRI, was labeled as HIV dementia. In the ED, initial vs were: 101.8 110 81/53 20. HCT 18 Patient was talking, but AAOx0. Patient was given 2L NS, 2 units of pRBC. Got dose of Vanc, zosyn, BCx drawn. Past Medical History: #HIV/AIDS--CD4-57/4%, VL [Numeric Identifier 14614] on [2101-10-5], not on meds since then; Nadir CD4 57 prior to [5-/2103] admit, no documented thrush or CMV in past Prior treatment includes: LAM/ZDV/EFV, ?NFV; TDF/FTC with FD LPV/r (started [2096-11-26], stopped [2096-12-19] due to diarrhea but restarted by [1-3], discontinued by [7-/2097]); TDF/FTC and ATV/r (started [7-/2098], self-discontinued [12/2098]) RPR non-reactive [2099-5-5]. Toxo IgG negative [2097-6-11]. HCV Ab negative [2094-8-10]. #pneumonia [11/2096] (Admitted [Hospital1 112]) thought to be viral #History of anorectal HPV. Last High resolution anoscopy [2099-6-30], path with AIN I x 2. Last anal pap done on that day. Social History: Patient lives alone at [Company 3596]. Patient works with [Hospital1 9060], processing donations. Tobacco: 1 ppd x 12 years ETOH: none Recreational drugs: none Family History: No family history of cancer, neurological issues, heart disease. Physical Exam: Admission PE: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear, no visible signs of thrush Neck: supple, JVP not elevated, no LAD Lungs: Good air movement b/l, +wet crackles at R base CV: Sinus tach, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: LE equal [5-17], UE equal [5-17]. Sensation grossly intact, -babinskis. Discharge PE: VS: 97.4, 116/70, 77, 18, 97%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear, no visible signs of thrush Neck: supple, JVP not elevated, no LAD Lungs: Good air movement b/l, +wet crackles at R base CV: Sinus tach, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: LE equal [5-17], UE equal [5-17]. Sensation grossly intact, -babinskis. Pertinent Results: Admission labs: [2103-7-9] 03:00PM BLOOD WBC-2.1* RBC-2.16# Hgb-6.7# Hct-18.7# MCV-87 MCH-30.9 MCHC-35.6 RDW-16.8* Plt Ct-24# [2103-7-10] 09:02AM BLOOD WBC-2.7 RBC-2.54* Hgb-7.7* Hct-21.4* MCV-84 MCH-30.3 MCHC-36.0* RDW-16.2* Plt Ct-17* [2103-7-9] 03:00PM BLOOD Neuts-47* Bands-6* Lymphs-38 Monos-2 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-2* NRBC-1* Other-4* [2103-7-9] 03:00PM BLOOD PT-13.4 PTT-22.6 INR(PT)-1.1 [2103-7-10] 12:56AM BLOOD PT-15.1* PTT-28.4 INR(PT)-1.3* [2103-7-9] 03:00PM BLOOD Glucose-121* UreaN-33* Creat-1.4* Na-128* K-4.3 Cl-99 HCO3-20* AnGap-13 [2103-7-10] 09:02AM BLOOD Glucose-106* UreaN-20 Creat-1.1 Na-134 K-3.3 Cl-107 HCO3-19* AnGap-11 [2103-7-9] 03:00PM BLOOD ALT-15 AST-48* LD(LDH)-1143* AlkPhos-86 TotBili-0.6 [2103-7-10] 12:56AM BLOOD LD(LDH)-576* [2103-7-10] 12:56AM BLOOD Calcium-7.2* Phos-2.1* Mg-2.0 [2103-7-10] 09:02AM BLOOD Calcium-7.6* Phos-2.7 Mg-1.9 [2103-7-10] 01:52AM BLOOD Type-ART Temp-39.4 pO2-103 pCO2-28* pH-7.44* calTCO2-20* Base XS--3 Intubat-NOT INTUBA Comment-101F AXILL [2103-7-9] 03:04PM BLOOD Glucose-112* Lactate-2.3* K-3.7 [2103-7-9] 04:46PM BLOOD Hgb-5.8* calcH SEROLOGY/BLOOD . Other labs: BAL: Negative for PCP, [Name10 (NameIs) 14616], AFB negative Quantiferon Gold TB test: indeterminate [2103-7-10] 02:45PM BLOOD PEP-NO SPECIFI IgG-1245 IgA-360 IgM-73 IFE-NO MONOCLO [2103-7-18] 05:12PM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-631* Polys-1 Lymphs-89 Monos-10 [2103-7-18] 05:12PM CEREBROSPINAL FLUID (CSF) TotProt-34 Glucose-75 [2103-7-18] 05:12PM CEREBROSPINAL FLUID (CSF) CSF-PEP-POSITIVE * [2103-7-18] 05:12PM CEREBROSPINAL FLUID (CSF) HISTOPLASMA ANTIGEN-PND . Micro: CRYPTOCOCCAL ANTIGEN (Final [2103-7-10]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. URINE HISTO AG: + . Imaging: CT Head: IMPRESSION: No acute intracranial process. . MRI Head: Prominence of ventricles and sulci consistent with global cerebral atrophy given the history of HIV/AIDS. Few T2 and FLAIR hyperintensities in the subcortical and periventricular white matter consistent with chronic small vessel ischemic disease. . CT chest [7-11]:Multifocal ground-glass pulmonary abnormality is relatively [Name2 (NI) 14617] terms of extent, but in the setting of severe neutropenia it could indicate relatively widespread and serious infection, including pathogenic bacteria aswell as viral infection. Pneumocystis is less likely because of therelatively small voluem of pulmonary involvement. Pulmonary hemorrhage is analternative explanation for the lung findings. Widespread adenopathy, more significant for number and distribution than size, is more likely HIV related than lymphoma although abdominal adenopathy and splenomegaly are considerable. . CT Abdomen/Pelvis [2103-7-13]: Multiple ill-defined hepatic hypodensities without appreciable enhancement, and porta hepatis lymphadenopathy. These findings may be compatible with infiltrative hepatic lymphoma, and a lesion in the lower aspect of segment [Doctor First Name ] may be amenable to percutaneous biopsy as long as the hemangioma in that segment is avoided. . TTE [2103-7-17]: Normal global and regional biventricular systolic function. No pulmonary hypertension or clinically-significant valvular disease seen. Very small pericardial effusion. EF >55%. . Path: SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY: DIAGNOSIS: DIFFUSE INVOLVEMENT BY NON-HODGKIN'S LYMPHOMA (DIFFUSE LARGE B-CELL LYMPHOMA). MICROSCOPIC DESCRIPTION Peripheral Blood Smear: The smear is adequate for evaluation. Erythrocytes are decreased in numbers, and exhibit moderate anisopoikilocytosis with polychromatophils, echinocytes, dacrocytes, and rare red cell fragments. Nucleated red blood cells are noted on scan. The white blood cell count appears decreased. Platelet count appears markedly decreased; large and giant forms are seen. Differential shows: 49% neutrophils, 5% bands, 25% lymphocytes, 10% monocytes, 1% eosinophils, 5% myelocytes, 3% blasts, 2% metamyelocytes. Aspirate Smear: Not submitted. Clot Section and Biopsy Slides: The biopsy material is adequate for evaluation, and consists of a 1.3 cm bone biopsy diffusely infiltrated with large cells with moderate amounts of pink cytoplasm, irregularly shaped nuclei with clumpy chromatin, and prominent nucleoli. No residual marrow elements are appreciated. By immunohistochemistry, these cells are positive for pan B-cell markers CD20, CD79, PAX-5, CD5 (major subset), BCL-6 (subset, dim), and BCL-2. They are negative for BCL-1, CD10, CD15, CD30, TdT, MPO, C-kit, and CD34. LMP appears negative (non-specific cytoplasmic positivity seen in scattered cells). CD3 highlights admixed T-cells. The proliferation index is 70% by MIB-1 staining. Overall, the findings are consistent with involvement by a high grade diffuse large B-cell lymphoma (de [Last Name (un) 11083] CD5 positive large cell lymphoma). Please refer to cytogenetics and flow cytometry studies for further information. ADDENDUM: Bone marrow [Last Name (un) ]-in situ hybridization reveals few scattered cells positively hybridized, far beyond the non-reactive negative control. In the bone marrow, a few scattered [Last Name (un) ] positive cells provides sufficient evidence that this lymphoid proliferation is EBV driven. Clinical correlation is recommended. FLOW CYTOMETRY REPORT FLOW CYTOMETRY IMMUNOPHENOTYPING The following tests (antibodies) were performed: HLA-DR, FMC-7, Kappa, Lambda, and CD antigens 3, 5, 10, 13, 19, 20, 23, 34. RESULTS: Three color gating is performed (light scatter vs. CD45) to optimize blast/lymphocyte yield. Abnormal/lymphoma cells comprise 14% of total gated events. B cells demonstrate a double (Kappa and Lambda) positive light chain population. They co-express pan B-cell markers CD19 and 20, along with CD5. They do not express any other characteristic antigens including CD10 or FMC-7. These abnormal B-cells are present in the blast window. INTERPRETATION Immunophenotypic findings consistent with involvement by an abnormal population of B-cells that are CD5-positive and seen within the blast window. The findings are consistent with the B-cell lymphoma recently diagnosed in the marrow. Labs on discharge: White Blood Cells 1.9* 4.0 - 11.0 K/uL Red Blood Cells 2.53* 4.6 - 6.2 m/uL Hemoglobin 7.5* 14.0 - 18.0 g/dL Hematocrit 21.3* 40 - 52 % MCV 84 82 - 98 fL MCH 29.5 27 - 32 pg MCHC 35.0 31 - 35 % RDW 15.9* 10.5 - 15.5 % DIFFERENTIAL Neutrophils 94* 50 - 70 % Bands 0 0 - 5 % Lymphocytes 1* 18 - 42 % Monocytes 4 2 - 11 % Eosinophils 1 0 - 4 % Basophils 0 0 - 2 % Atypical Lymphocytes 0 0 - 0 % Metamyelocytes 0 0 - 0 % Myelocytes 0 0 - 0 % RED CELL MORPHOLOGY Hypochromia 1+ Anisocytosis 1+ Poikilocytosis 1+ Macrocytes OCCASIONAL Microcytes OCCASIONAL Polychromasia NORMAL Target Cells 1+ Burr Cells OCCASIONAL BASIC COAGULATION (PT, PTT, PLT, INR) Platelet Smear RARE Platelet Count 10* 150 - 440 K/uL MISCELLANEOUS HEMATOLOGY Granulocyte Count 1795* 2200 - 8250 #/uL Platelet Count 15* 150 - 440 K/uL post transfusion Test Name Value Reference Range Units [2103-8-25] 06:18 Source: Line-PICC RENAL & GLUCOSE Glucose 95 70 - 100 mg/dL IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES Urea Nitrogen 22* 6 - 20 mg/dL Creatinine 0.5 0.5 - 1.2 mg/dL Sodium 135 133 - 145 mEq/L Potassium 3.0* 3.3 - 5.1 mEq/L Chloride 108 96 - 108 mEq/L Bicarbonate 23 22 - 32 mEq/L Anion Gap 7* 8 - 20 mEq/L ENZYMES & BILIRUBIN Alanine Aminotransferase (ALT) 22 0 - 40 IU/L Asparate Aminotransferase (AST) 11 0 - 40 IU/L Lactate Dehydrogenase (LD) 168 94 - 250 IU/L Alkaline Phosphatase 71 40 - 130 IU/L Bilirubin, Total 0.9 0 - 1.5 mg/dL CHEMISTRY Albumin 2.2* 3.5 - 5.2 g/dL Calcium, Total 7.3* 8.4 - 10.3 mg/dL Phosphate 2.9 2.7 - 4.5 mg/dL Magnesium 2.0 1.6 - 2.6 mg/dL Uric Acid 2.2* 3.4 - 7.0 mg/dL Brief Hospital Course: 49 yo M w AIDS (CD4 22, VL 891K [2103-6-15]) presents s/p fall with new anemia, pancytopenia, fever and altered mental status. He was initially transferred to [Hospital Unit Name 153] for hypotension (FAST negative). Hospital course has been notable for lymphoma diagnosed on bone marrow biopsy, BAL with negative PCP, [Name10 (NameIs) ] and urine with positive histo ag, prolonged pancytopenia, and hypotension. . Hospital Course by Problem: . #Hypotension: On presentation to the ED, he was febrile to 101.8, A&Ox0, and hypotensive to 81/53. Labs showed acutely worsened anemia with Hct of 18.7 - stool was brown, guiaic +. Plts had fallen to 24. WBC was 2.1 w/ left-shift. He was given 2U PRBC + 2L IVF in ED along with Vanc/Zosyn and admitted to the [Hospital Unit Name 153]. In the [Hospital Unit Name 153], he was given additional 1U PRBC and 1L IVF with improvement in his BPs. After stabilization, he was transferred to the medicine floor. He later triggered several times for hypotension, but was asymptomatic during these episodes. A cosyntropin stimulation test diagnosed adrenal insufficiency, likely from [Hospital1 ] therapy and possible HIV. He was put on hydrocortisone, then switched to prednisone. His blood pressure has remained stable, and he was discharged on 5mg daily prednisone. . #Anemia: GI was consulted for acute anemia and guiaic+ stool, they recommended inpatient EGD/colonoscopy after further stabilization. Pt stabilized and these procedures were not done. Pt remained pancytopenic and required high number of transfusions, likely secondary to underlying lyphoma, and also ambisome that pt was put on. Transfusion requirement tapered down after ambisome was stopped. Continues to require blood transfusions approximately 2x/week. . #Lymphoma: Patient had a bone marrow biopsy to evaluate pancytopenia which was a dry tap and pathology with diffuse large B-cell lyphoma, Bcl-2 +, Bcl-6 +, and CD10 negative. The hypodense liver lesions were thought to be [2-14] lymphoma and liver biopsy was deferred given risk of bleeding with patient??????s pancytopenia. LP flow was inconclusive, but did not demonstrate many cells. Patient got IT MTX [2103-7-18]. was started on Dexamethasone [Date range (1) 14618]. Started [Hospital1 ] [2103-7-21] and completedd on [7-25]. He then had a prolonged pancytopenia, and started to recover his counts on [8-10]. However, he then started having fevers once again, and a second cycle of [Hospital1 ] was administered starting [2103-8-19], and was well-tolerated. He will receive daily neupogen starting [2103-8-24] until the next cycle of [Hospital1 ] commences on [2103-9-9]. . #Histoplasmosis: Urine was histo ag positive. CSF histo ag was negative. Patient was started on Ambisome but then later switched to itraconazole, which per ID he will likely need for life. . #Hyponatremia: On admission to BMT service on [7-18], Na was 125. Likely hypovolemic hyponatremia given improvement with hydration via NS. . #AIDS: Patient was seen by Infectious Disease and started on ART along with ppx for PCP and MAC. Darunovir and Ritonavir were discontinued because they interact with chemotherapy agents and he was instead started on another protease inhibitor, Raltegravir. He was given pentamidine on [8-8]. He will continue on prophylactic acyclovir, azithromycin and atovaquone. . #Fever: Initially differential included infectious vs neoplastic processes primarily. CT imaging was notable for patchy ground glass opacities, hepatomegaly with hypodense liver lesions, splenomegaly and diffuse adenopathy. Patient was isolated for TB and was empirically treated for PCP with prednisone and Bactrim (prednisone for transient hypoxia/[Doctor First Name ]) until BAL was negative for PCP. [Name10 (NameIs) ] cxs were unremarkable, but given degree of immunosuppression patient was empirically treated for bacterial pneumonia with Vancomycin/Zosyn/Levofloxacin for a 14 day course. In regards to TB, Quantiferon gold was indeterminate but a [Name10 (NameIs) ] culture from [7-17] was positive for acid-fast bacilli. He had 3 negative [Month/Day (1) ] smears, twice (done in early [Month (only) 205], and again in late [Month (only) 205]). Fevers from lymphoma vs infectious, but had resolved by mid [Month (only) 205]. Upon recovery of his coutns following cycle 1 of [Hospital1 ], he started having fevers once again. Chest X-ray was unclear regarding possible pneumonia as a source of fevers, and he was initially started on antibiotics. However, repeat chest X-rays did not supprot a diagnosis of pneumonia, and the patient clinically had no evidence of chest pathology. Fevers were then thought to be due to malignancy. Following initiation of Cycle 2 of [Hospital1 ], the fevers resolved. . #Altered Mental Status: This was felt to be most likely [2-14] HIV dementia. LP did not demonstrate bacterial infection and viral CSF work up was deferred by recommendation of ID team given recent negative work up in early [Month (only) ]. An MRI head demonstrated significant brain atrophy and large ventricles but no evidence of CNS lymphoma. He was A&Ox3 with intermittent confusion about recent events. Towards the end of [Month (only) 205], he was substantially improved though, with much less confusion and more orientation. . # Hypokalemia: pt had a persistant hypokalemia in the middle to end of [Month (only) 205]. This was thought to be secondary to ambisome therapy, which has a high incidence of electrolyte abnormalities. Work-up revealed high levels of renal pottasium wasting. If hypokalemia does not resolve, he may have an underlying RTA. #Thrombocytopenia: Patient was found to be thrombocytopenic since admission. This is likely long-standing, and may be unrelated to lymphoma. Review of his medication list and elimination of medications that might possibly have been causing thrombocytopenia did not improve thrombocytopenia. Splenic sequestration may be contibuting to thrombocytopenia. Patient also became refractory to platelet transfusions, and an anti-platelet antibody screen was found to be positive. He was therefore administered a five-day course of IVIG to neutralise the anti-platelet antibodies. This resulted in some, but not complete improvement in response to platelet transfusions. Medications on Admission: PATIENT WAS UNABLE TO VERIFY MEDICATIONS; THESE ARE DISCHARGE MEDICATIONS FROM A PREVIOUS VISIT** 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID (3 times a day) as needed for thrush. 5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for Groins/inner thigh. 6. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK ([Doctor First Name *]). 8. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. darunavir 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. ritonavir 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). . Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s)* Refills:0 2. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK (MO). Disp:60 Tablet(s) Refills:2 5. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID (3 times a day). Disp:450 ML(s) Refills:2 6. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:30 Patch 24 hr(s) Refills:2 7. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:2 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. itraconazole 100 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:90 Capsule(s) Refills:2 11. oral wound care products Gel in Packet Sig: One (1) ML Mucous membrane TID (3 times a day). Disp:90 ML(s) Refills:2 12. quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:30 Tablet(s) Refills:0 13. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). Disp:30 Refills:2 14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 15. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:0 16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for constipation. Disp:90 Capsule(s) Refills:0 17. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO once a day as needed for constipation. Disp:500 ML(s) Refills:0 18. filgrastim 300 mcg/mL Solution Sig: One (1) Injection Q24H (every 24 hours) for 15 days. Disp:15 Refills:0 19. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 20. atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO once a day. Disp:60 Refills:2 21. Lidocaine Viscous 2 % Solution Sig: One (1) Mucous membrane three times a day as needed for mouth pain. Disp:60 Refills:0 22. miconazole nitrate 2 % Powder Sig: One (1) Topical three times a day as needed: apply to groin, other fungal skin rash as needed. Disp:qs Refills:0 Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Primary: Lymphoma Adrenal insufficiency . Secondary: HIV/AIDS Discharge Condition: Level of Consciousness: Alert and interactive. Mental Status: Confused - sometimes. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Known lastname 14619], It was a pleasure taking care of you during your admission to [Hospital1 69]. You were admitted after a fall with fevers and confusion. Your fever was thought to be secondary to an infectious process and you were treated with antibiotics after which your temperature normalized. We tested you for tuberculosis and found that that you do not have it. A fungal infection (histoplasma) was found in your urine and we treated you with antibiotics. You also had low blood counts and a bone marrow biopsy was done to investigate the cause. The results of the biopsy demonstrated that you have lymphoma. A lumbar puncture was done to determine whether or not you had disease in the fluid and you were empirically treated with injection of a chemotherapy [Doctor Last Name 360] into the spinal fluid. You were treated for the lymphoma with intravenous chemotherapy. Your counts went down very low, but then rose back up around [8-11]. You also had low blood pressure, and were diagnosed with adrenal insuffiency, for which you will need to take a steroid. You were subsequently treated with a second round of intravenous chemotherapy, which you tolerated well. . The following changes were made to your medications: HAART regimen (for AIDS): -DISCONTINUED: darunavir and ritonavir -STARTED: raltegravir It is VERY important that you take these medications daily because not only do they treat AIDS but they also help your body to fight the lymphoma - Nicotine patch - Prednisone - Itraconazole - this is an anti-fungal for the histoplasma - Azithromycin - Atovaquone - Acyclovir - Oral Gel - Viscous Lidocaine - Quetiapine - Omeprazole - Bowel regimen (senna, sodium docusate, polyethylene glycol, lactulose) - Filgastrim Please followup with your oncology and infectious disease doctors, see below. Followup Instructions: Please followup with Dr. [Last Name (STitle) ] on Wednesday [2103-8-29]. You will be contact[Name (NI) ] by Dr. [Last Name (STitle) 14620] office with the final time of the appointment on Wednesday. Please call [Telephone/Fax (1) 3237] if you have not heard from them by Monday afternoon, or if you have any other questions. Department: INFECTIOUS DISEASE When: MONDAY [2103-9-10] at 10:00 AM With: [Name6 (MD) 14621] [Last Name (NamePattern4) 14622], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 3922] Completed by:[2103-8-27]	[ "584.9", "792.1", "284.1", "288.00", "255.41", "287.31", "202.80", "786.4", "042", "511.9", "486", "294.10", "276.8", "115.99", "780.61", "276.1", "276.2", "787.91", "799.4" ]	icd9cm	[ [ [] ] ]	[ "38.97", "41.31", "33.24", "03.92", "99.25" ]	icd9pcs	[ [ [] ] ]	22118, 22188	12033, 12462	349, 432	22294, 22341	4136, 4136	24367, 25170	2861, 2927		19522, 22095		22209, 22273		18498, 19499			22479, 24344									2942, 3513																							3527, 4117	264, 311			10416, 12010		12490, 16934					460, 1871			5972, 10397				4153, 5336				22356, 22455				1893, 2655	2671, 2845			5348, 5963
14,579	127,016	6973	Discharge summary	report	Admission Date: [2125-2-15] Discharge Date: [2125-3-4] Date of Birth: [2056-5-19] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2597] Chief Complaint: Ulceration of right hallux with bone exposure Major Surgical or Invasive Procedure: Amputation of rigth hallux History of Present Illness: : 68 yo male is direct admit who is to undergo surgery on Friday. Pt has been seen in [Hospital ] clinic for ulcer on right foot . Pt states that the ulcers have been present for extended periods of time. He had undergone surgery in [Month (only) 205] for his 5th digit. He then developed callus which lead to an ulcer on his right big toe. Pt admits to numerous office debridements and wound care techniques. Pt admits to using wet to dry dsg, offloading, felted foam dressing and currently regranex. At last visit, he underwent a percutaneous flexor tenotomy on hallux to try and relieve tension causing the increased pressure on the toe. Pt admits to noticing redness and drainage form the area. He is currently on Augmentin for both ulcerations on right foot. Pt also has felted foam dressing placed at his last visit. He denies N/V/F/Sob/chills. Pt states that he spoke with Dr [Last Name (STitle) ] regarding having a part of the toe amputated. Past Medical History: PMH: DM2 HTN increase cholesterol CAD MI [2121] Renal artery stenosis GERD Lung CA PSH: LLL adeno CA with resection Fem-po [2111] aortofemoral BPG [2118] Cardiac cath with stent x 6 Social History: pos alcohol - occ pos tobacco - quit 10 yrs ago 40 pyh Family History: Mother deceased 54 - DM Father deceased 58 - accident Sister - CAD/MI/STROKE Daughter - bladder ca Physical Exam: General: No apparent distress, alert and oriented x3. HEENT: Head NC/AT. Sclerae anicteric, PERRLA, EOMs intact, Cardiac: RRR, S1, S2 Pulmonary: Decr BS, basilar crackles Abdomen: Soft, nontender, non-distended. BS present in all 4 quadrants. Extremities: DP and PT pulses non-palpable. Protective sensation diminished b/l. An ulceration measuring noted over the plantar aspect of the right hallux. Exposed bone & IPJ. Localized erythema noted surrounding the ulcer. No purulence noted. No malodor noted. Over lateral aspect fo right forefoot, macerated, superficial wound noted. The wound measures 1 x2 cm. Within this wound, there are two area noted to probe to soft tissue. No bone involvement noted. No cellulitis or lymphangitis noted. New superficial ulcer dorsal PIPJ of [3-17]? Digit, not probe to bone, no purulence or cellulitis. s/p multiple toe amputations. Neuro: CNs: II-XII intact to direct testing. Motor: Tone normal. Strength 5/5 throughout. Pertinent Results: [2125-2-15] RIGHT FOOT, THREE VIEWS: Since [2124-7-14], there has been increased osteolysis and irregularity of the margins of the prior fifth metatarsal amputation site, seen on ly on the AP view. The finding lies deep to the soft tissue ulcer of the lateral foot. The appearance of the resected first distal phalanx and second distal metatarsal are unchanged. The remaining osseous structures are demineralized, suggesting disuse. IMPRESSION: Interval development of irregular margins of the fifth metatarsal osteotomy site. While this could represent an atypical of healing, given its proximity to the skin ulcer, osteomyelitis should also be considered. . P-mibi [2125-2-16]: IMPRESSION: 1. Abnormal myocardial perfusion. Severe perfusion defect of the inferior wall which is mildly reversible at the apex. Moderate, reversible defect of the inferolateral wall. 2. Global hypokinesis and akinesis of the inferior wall with a calculated ejection fraction of 39%. . [2125-2-16] ART EXT: FINDINGS: Doppler evaluation shows monophasic waveforms diffusely and bilaterally, those at the PT level are absent bilaterally. ABI measurements could not be obtained on the right due to absent pulses and overlying bandage, on the left, the ABI is 0.45. The volume recordings demonstrate diffuse waveform widening and extremely low amplitude at the metatarsal levels bilaterally. IMPRESSION: Findings as stated above which indicate significant aortoiliac disease. There is likely SFA/popliteal disease and definite tibial disease bilaterally. . [2125-2-16] CT chest without contrast: 1. No evidence of tumor recurrence, status post left upper lobectomy. 2. Moderate centrilobular emphysema. 3. Nonspecific interstitial changes of the lung bases likely represent scarring or fibrosis. These appear unchanged from the prior examination. . Cardiac cath [2125-2-19]: 1. Selective coronary angiography revealed a right dominant system. LMCA had a 50% tapering distal lesion that was calcified and unchanged from prior angiogram in [2123]. LAD was calcified with a mid-segment 60% lesion. LCX was non-dominant with 50% OM1 lesion. RCA was a dominant vessel that was proximally occluded with robust L->R collaterals. 2. Pressure wire measurement across the LMCA showed an FFR of 0.83 at maximal hyperemia which was consistent with a hemodynamically non-significant lesion. 3. Left ventriculography showed preserved ejection fraction. 4. Limited hemodynamic assessment showed mildly elevated systemic pressures and no aortic valve gradient. 5. Abdominal aortography showed patent aorto-bifemoral bypass without iunflow lesions. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease (mild to moderate). 2. Normal ventricular function. Brief Hospital Course: A/P: 68 yo with DM, CAD s/p stents, HTN, Hyperlipidemia here with elective amputation for osteo of foot but was found to be hypoxic and p-mibi now showing moderate. . #. Hypoxia: The patient was satting 91% on RA at admission. After receiving IV lasix, hypoxia resolved. Repeat CXR was consistent with emphysema, and MDI was started. Repeat CT of chest without contrast did not show any evidence of recurrent lung cancer. . #. CAD: As a pre-op clearance, a P-mibi was done and showed severe perfusion defect of the inferior wall which is mildly reversible at the apex and a moderate, reversible defect of the inferolateral wall. For this abnormal finding, the patient undwernt cath which reveals stable lesions compared to the previous cath in [2123] and no intervention was done. The patient was continued on BB, ASA, ACEI, and statin. . # CHF: EF was normal 54% per cath report on [2125-2-19]. The patient likely has diastolic dysfunction. The patient was continued on BB, ACEI, and lasix maintenance dose after iv diuresis. . #. h/o lung adenocarcinoma: CXR showed irregular parenchymal densities in R lung and vague opacity in L para-aortic area. CT of chest without contrast however did not reveal any evidence of recurrence. . #. Microcytic Anemia: The patient was on iron as an outpatient. Hem/onc (Dr. [Last Name (STitle) 6944] was consulted and the patient was found to be vitamin B12 deficiency. homocystein was normal and MMA is pending. Iron studies were consistent with anemia of chronic disease +/- iron deficiency anemia in the setting of chronic ulcer/osteomyelitis. The patient was transfused 2 units in the setting of hypoxia and anticipated surgery and hct increased appropriately. Guaiac was negative. . # Osteomyelitis: Pt admitted to podiatry for pre-operative admit for amputation of right hallux. On admission, pt noted to have a complex medical history. Pt noted to have non-palpable pulses. NIAS obtained and pt found to have poor perfusions rate. W-dry dressign to hallux continued until furtehr intervention possible. Pt remained on Unasyn while getting cardiac clearance and resolution of hypoxia. Once hypoxia resolved and cardiac cleared, the patient was transferred to [Last Name (STitle) ] Surgery service for appropriate intervention. . #. DM: Hypoglycemia of 42 in the setting of change in diet and NPO. The patient's pm NPH and standing regular were decreased to 10 and 12 respectively to prevent hypoglycemia. (home dose NPH 15 am 20 pm, Regular 10 am, 15 pm) . #. HTN: Stable. Titrated up BB and ACEI for better BP control. Continued maintenance lasix. . # Hyperlipidemia: Continue lipitor 80mg qday . # [Last Name (STitle) ]: Pt had a failing right limb of aortobifemoral and right femoral dorsalis pedis vein graft. The pt underwent a exploration of right groin, right common and profunda femoris artery endarterectomy and Dacron patch angioplasty. There were no complications. Pt tolerated the procedure well. Normal postoperative care. . # FEN: [Doctor First Name ], cardiac diet. Replete 'lytes K to 4 and mag to 2. . # Code: Full Medications on Admission: Furosemide 80mg daily Lipitor 80mg daily Metoprolol 100mg [Hospital1 ] Lisinopril 20mg daily Fe Sulfate 65mg daily ASA 81mg daily Insulin AM: 15U NPH 10 Regular PM: 20U NPH 15 Regular Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:30 Tablet(s) Refills:0 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:45 Tablet(s) Refills:0 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 7. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:2 8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 14 days. Disp:42 Tablet(s) Refills:0 10. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 11. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab Sublingual prn as needed for chest pain. Disp:60 tab Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 8300] VNA Discharge Diagnosis: Osteomyelitis of right hallux Discharge Condition: good Discharge Instructions: Go to an Emergency Room if you experience new and continuing nausea, vomiting, fevers (>101.5 F), chills, or shortness of breath. Also go to the ER if your wound becomes red, swollen, warm, or produces pus. You may remove your dressings 2 days after your surgery if they were not removed in the hospital. Leave the steri strips on until they begin to peel, then you may remove them. Staples and stitches will remain until your follow-up appointment. If you experience clear drainage from your wounds, cover them with a clean dressing and stop showering until the drainage subsides for at least 2 days. No heavy lifting or exertion for at least 6 weeks. No driving while taking pain medications. Narcotics can cause constipation. Please take an over the counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. Be sure to take your complete course of antibiotics. You may resume your regular diet as tolerated. You may take showers (no baths) after your dressings have been removed from your wounds. Take a shower immediately before dressing changes by the visiting nurse. Restart your home medication as usual. You may weight bear on the Right heel ONLY. No weight to right forefoot and toes. Followup Instructions: 1. Provider: [Name10 (NameIs) 1111],[First Name7 (NamePattern1) 1112] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] SURGERY (NHB) Date/Time:[2125-3-12] 1:30 ([Telephone/Fax (1) 18181] 2. Provider: [Name10 (NameIs) ] [Name11 (NameIs) 3627] [Name12 (NameIs) 3628] [Name12 (NameIs) ] [Name12 (NameIs) 3628] (NHB) Date/Time:[2125-3-12] 1:00 3. Please follow up with Dr [Last Name (STitle) ] 7-10 days after discharge. ([Telephone/Fax (1) 4335] Completed by:[2125-3-5]	[ "440.23", "707.8", "799.02", "440.31", "V10.11", "266.2", "272.0", "730.27", "731.8", "518.81", "730.07", "250.80", "496", "440.1", "285.29", "414.01", "413.9", "428.0", "E878.2" ]	icd9cm	[ [ [] ] ]	[ "88.56", "88.42", "96.72", "96.04", "38.91", "84.11", "39.49", "88.53", "38.18", "99.04", "38.93", "39.57", "37.22", "00.40" ]	icd9pcs	[ [ [] ] ]	10105, 10164	5580, 8694	359, 388	10238, 10245	2808, 5448	11560, 12096	1697, 1797		8953, 10082		10185, 10217		8720, 8930		5465, 5557	10269, 11537									1812, 2789																								274, 321										417, 1387															1409, 1608	1624, 1681
22,879	179,580	17892+17893+17894	Discharge summary	report+report+report	Admission Date: [2154-2-4] Discharge Date: [2154-2-20] Date of Birth: [2099-5-31] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: The patient complained of chest tightness, dyspnea and palpitations for the past month. PAST MEDICAL HISTORY: 1. Hypertension. 2. Gout. 3. L4 through L5 and S1 through S2 herniated disks. 4. Pin implant in the left fifth finger. PAST SURGICAL HISTORY: Status post cholecystectomy. SOCIAL HISTORY: The patient is a previous smoker but quit 20 years ago. MEDICATIONS AT HOME: 1. Aspirin 325 q. day. 2. Lisinopril 10 mg q. day. ALLERGIES: The patient has no known drug allergies. REVIEW OF SYSTEMS: Negative for myocardial infarction, transient ischemic attack, cerebrovascular accident, claudication, orthopnea, hepatitis or peptic ulcer disease. PHYSICAL EXAMINATION: Vital signs were heart rate 70s in sinus rhythm, blood pressure 110/70. The patient was alert and oriented x 3. There was no jugular venous distension, no bruits. Chest was clear to auscultation. Cardiovascular examination was regular rate and rhythm, S1 and S2, no S3 or S4 and a 3/6 systolic ejection murmur. Abdomen had positive bowel sounds, nontender, nondistended. Extremities had no cyanosis, clubbing or edema. An echocardiogram done in [2153-12-15] showed an ejection fraction of 60%, severe atrial fibrillation, mild mitral regurgitation, mild aortic insufficiency and left ventricular hypertrophy. Cardiac catheterization on [2154-2-4] showed preserved left ventricular ejection fraction, left anterior descending 60% mid vessel, obtuse marginal #1 40%, no mitral regurgitation, moderate aortic stenosis with an aortic valve area of 0.7 cm. LABORATORY DATA: White blood cell count was 11.6, hematocrit 44.6, platelet count 200, BUN 21, creatinine 1.0, liver function tests within normal limits and a negative urinalysis. HOSPITAL COURSE: The patient was admitted on [2154-2-4] and taken to the operating room on [2154-2-5] for an aortic valve replacement with a [Street Address(2) 11688]. [Male First Name (un) 923] mechanical valve and a coronary artery bypass grafting x 1 with left internal mammary artery to the left anterior descending coronary artery. Anesthesia was reversed and the patient was transferred to the intensive care unit where he was successfully weaned from vasopressors and was extubated on postoperative day one. Chest tubes and pacing wires were discontinued on postoperative day three and he was transferred to the floor for continued recovery and rehabilitation. He was placed on heparin and Coumadin for anticoagulation. On postoperative day four he began experiencing significant dyspnea with diaphoresis and decreased blood pressure as well as tachycardia. He was transferred back to the CSRU. Chest x-ray revealed hematoma in the left middle lobe. A chest CT was also done and showed no evidence of a PE. A large pericardial effusion was present as well as moderate-sized bilateral pleural effusions and a loculated effusion on the left. The patient was aggressively diuresed and respiratory status improved. He was also transfused with two units of packed red blood cells for a 6% hematocrit drop. The Coumadin and heparin were discontinued. Renal was consulted for increasing creatinine as well as decreased urinary output. An echocardiogram was done and showed left ventricular ejection fraction of 55% and mildly dilated left atrium. The patient remained in the intensive care unit for the next several days. He had remitting episodes of shortness of breath that responded well to diuresis. Chest x-ray remained stable. On postoperative day six creatinine was trending downward and urine output was improving. He was started on levofloxacin for a positive urinalysis. Culture was pending. The patient began experiencing decreased appetite with some slight abdominal distention. Liver function tests were trending upward. GI was consulted. They believed this to be due to a low flow state. On postoperative day seven hematology was consulted for continued decreasing hemoglobin and hematocrit despite no evidence of real bleeding. On postoperative day eight the patient began improving with decreased liver function tests, increased appetite, decreased creatinine. Urine output was stable. Respiratory status was improving and hematocrit remained stable. On postoperative day nine he was transferred back to the floor. Physical therapy was involved with rehabilitation and anticoagulation was resumed. On postoperative day 10 the patient had some episodes of sinus tachycardia with bursts of wide complex tachycardia. Beta blocker was increased. No further episodes were noted. On postoperative day 12 the patient complained of right ankle pain and increased white blood cell count. Rheumatology was consulted. The joint was aspirated and fluid sent for culture. The results are still pending. Fluid analysis was consistent with pseudogout. He was treated with colchicine and intra-articular steroid injection with good pain relief. On postoperative day 13 the patient continued to have episodes of supraventricular tachycardia without a wide complex tachycardia. Cardiology was consulted. Beta blocker was changed from Lopressor to sotalol with no further episodes of supraventricular tachycardia noted. The patient continued to have the presence of bilateral pleural effusions. A right thoracentesis was performed and drained about 1.5 liters of bloody fluid. Culture was sent and was still pending, and a left thoracentesis was also performed and that drained about one liter of bloody fluid. At this point on postoperative day 15 the patient's respiratory status continues to improve. He is ambulating independently in the hallways. He is eating well, making sufficient urine and is continuing to recover nicely. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 17400] MEDQUIST36 D: [2154-2-20] 10:03 T: [2154-2-20] 10:17 JOB#: [Job Number 49602] Admission Date: [2154-2-4] Discharge Date: [2154-2-24] Date of Birth: [2099-5-31] Sex: M Service: ADDENDUM: It was our intention to discharge the patient earlier than [2154-2-24]. However, his amylase and lipase began to increase over the past four days or so mildly. It was our concern that the patient might turn out to have a pancreatitis. GI was consulted and indicated that we should go ahead and let the patient eat and treat him only symptomatically as opposed to following his amylase and lipase figures. The patient has been eating now for 24 hours and does not nor has he had abdominal pain. He is currently approaching the therapeutic point on his Coumadin. Therefore, he will be discharged tomorrow in good condition. The patient is to follow-up with Dr. [First Name (STitle) ] [Last Name (Prefixes) ] in four weeks. He is to follow-up with his PCP, [First Name4 (NamePattern1) 518] [Last Name (NamePattern1) 6700], in one to two weeks. The patient should not lift anything heavy. He should avoid strenuous activity. He should not drive while on pain medication. He may shower but should not take baths. The patient is to go to a laboratory of his choice and have his INR checked daily and have the result forwarded to his PCP for daily Coumadin dosing adjustment. DISCHARGE MEDICATIONS: 1. Sotalol 80 mg p.o. b.i.d. 2. Coumadin. 3. Oxycodone 5-10 mg p.o. q. four to six hours p.r.n. 4. Ipratropium q. six p.r.n. 5. Albuterol q. six p.r.n. 6. Pantoprazole 40 mg p.o. q.d. 7. Colace 100 mg p.o. b.i.d. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern4) 8358] MEDQUIST36 D: [2154-2-23] 02:15 T: [2154-2-23] 14:35 JOB#: [Job Number 49603] Admission Date: [2154-2-4] Discharge Date: [2154-2-25] Date of Birth: [2099-5-31] Sex: M Service: Cardiothoracic Surgery ADDENDUM: The patient was kept an extra two days secondary to increased incidence of cardiac arrhythmia. Cardiology was called to investigate and confirm that his arrhythmia was a paroxysmal ventricular tachycardia. It was their opinion that the patient won't have an adverse effect to this arrhythmia, although they did increase his sotalol from 80 to 120 mg which improved the arrhythmia which he has shorter bursts and less frequent bursts than he was having. The patient is being discharged on [2154-2-25] in good condition. He is being sent home with [Initials (NamePattern4) ] [Last Name (NamePattern4) ] of Hearts monitor that will be followed up by Dr. [Last Name (STitle) 1911] and his Coumadin and INR checks will be followed daily by Dr. [First Name4 (NamePattern1) 518] [Last Name (NamePattern1) 6700]. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern4) 12487] MEDQUIST36 D: [2154-2-25] 10:09 T: [2154-2-25] 10:34 JOB#: [Job Number 49604]	[ "427.1", "424.1", "414.01", "577.0", "584.5", "998.11", "997.5", "599.0", "511.8" ]	icd9cm	[ [ [] ] ]	[ "88.56", "36.15", "37.23", "35.22", "81.92", "81.91", "39.61", "99.23", "88.53", "34.91" ]	icd9pcs	[ [ [] ] ]									7543, 9293					1936, 7520						567, 674				441, 471														867, 1918						694, 844															182, 271															294, 417	488, 545
1,893	148,009	50434	Discharge summary	report	Admission Date: [2169-8-9] Discharge Date: [2169-8-17] Service: MEDICINE Allergies: Motrin Attending:[First Name3 (LF) 1436] Chief Complaint: Mrs. [Known lastname ] is an 86 year old woman with CAD, s/p CEA and MI as well as severe spinal stenosis with a L4 fracture admitted for cardiac catheterization to obtain cardiac clearance for anticipated spinal surgery due to a (+) exercise tolerance test with a moderate reversible lateral wall defect. Major Surgical or Invasive Procedure: Left heart catheterization [2169-8-9]: Selective coronary angiography of this right dominant system was difficult due to right brachial access with severe subcalvian artery tortuosity. Despite attempts with multiple catheters, we were not able to engage the LMCA. Sub-optimal images of the RCA demonstrated a probably 60% distal stenosis. 2. Left ventriculography was deferred. 3. Limited resting hemodynamics demonstrated markely elevated systemic systolic pressure. Left heart catheterization [2169-8-10]: right dominant system. LMCA: nl LAD: 40% fter D1. LCX: mid vessel 50% stenosis at the origin of the OM1. The OM1 had a tubular ostial/proximal stenosis of 70%. RCA: 70% ostial stenosis, a 50% mid segment stenosis and a 90% distal segment stenosis before the PDA/PL bifurcation. 2. Resting hemodynamics reveal mild systemic arterial hypertension. 3. No left ventriculogram performed to reduce contrast load. 4. Despite prolonged attempts it was not possible to recannulate the RCA ostium and the procedure was terminated due to prolonged fluroscopy time. 1. Two vessel coronary artery disease. 2. Mild systemic arterial hypertension. History of Present Illness: 86 year old female with past h/o HTN, CAD s/p MI, severe spinal stenosis, and AIHA requiring chronic prednisone therapy presents to the CCU after hematocrit drop from 26 to 15.5 s/p cath. In preparation for spinal surgery patient was found to have 7 cm abdominal aortic aneurysm below the level of the renal arteries. Pt had a subsequent MIBI demonstrating a moderate reversible lateral wall perfusion defect and she was referred for cardiac catheterization. Left heart cath performed on [8-9] via right brachial artery due to limited femoral arterial pulses, aborted after unable to engage the LMCA. Distal RCA likely 60%. Pt returned to cath the next morning for second attempt at cardiac cath via femoral artery approach. Crit at this time 26. Selective coronary angiography demonstrated two vessel coronary artery disease in a right dominant system. The LMCA was without flow limiting disease. The LAD had a 40% stenosis after the D1. The LCX had a mid vessel 50% stenosis at the origin of the OM1. The OM1 had a tubular ostial/proximal stenosis of 70%. The RCA had a 70% ostial stenosis, a 50% mid segment stenosis and a 90% distal segment stenosis before the PDA/PL bifurcation. Received large contrast load. Despite prolonged attempts was not possible to recannulate the RCA ostium and the procedure was terminated due to prolonged fluroscopy time. right groin hematoma formed after cath. Pressure held for 23 minutes.hematocrit drop from 27 to 16.9. Received 2 liters NS. BP 120's, HR 70-90. 1 unit hung pt admitted to CCU for further management. Past Medical History: # Autoimmune Hemolytic anemia -- due to NSAID use; now on chronic prednisone # h/o bladder prolapse and urinary incontinence - uses pessary # Osteoporosis - likely [3-16] steroids - on actonel, Ca, vit D # CAD s/p MI - at age 65, no stents or CABG - ECHO = NL EF in [2164], no WMA, no valvular disease # s/p R carotid thromboendarterectomy (cholesterol embolism to eye) # Depression - on paxil # HTN - last BP in OMR was 150/78 # Asthma # Hard of hearing - has bilateral hearing aids # R distal radius fx s/p reduction and external fixation # s/p R pubic fx after a fall in [2165] # R cataract surgery Social History: Presently patient at [Hospital ] Rehab in [Location (un) 701]; had been in [Hospital3 ] facility until [2169-7-11] making own lunch, breakfast; dinner in common area; Daughter arranges daily pills -- patient takes independently; Widowed with one daughter and son-in-law very active in her care; + tob for many years, quit after MI at age 65; No ETOH/drugs Family History: No h/o seizures, back problems, strokes. Mother died of MI, father had DM. Daughter w/ DM, on insulin pump currently. Physical Exam: General- Elderly female very drowsy laying flat with echymoses over body. vitals-t 97.2, HR 95 BP 148/73, RR 21, 96%2 L skin-numerous echymoses over body primarily around left arm cath site and right thigh. Feet cool to the touch bilaterally. HEENT- cataracts bilaterally, hearing aid, unable to assess JVP, as pt laying down. carotid bruit present. CV- Tachycardic, regular rhythm. nml s1, s2, no murmurs rubs or gallops lungs- decreased breath sounds bilaterally. No wheesing heard abd- soft, non tender, mid abdominal scar, hypoactive bowel sounds, no hepatomegaly felt. no grey turners or cullens sign. ext- right arm hematoma, warm, well perfused. echymoses bilaterally. Atrophied feet, venous changes with erythema in the left leg. cooler feet. Faint femoral, PT pulses. Large right thigh hematoma, extending down thigh. Unable to assess for bruit given pressure bandage. Pertinent Results: [2169-8-1], CT [Last Name (un) 103] w w/o c 1. Infrarenal saccular aortic aneurysm and somewhat ectatic aorta as described. 2. Profound bony insufficiency with insufficiency fractures. [2169-8-9] 12:25PM HCT-26.9* [2169-8-9] 05:31PM HCT-30.3* L heart cath [8-9] 1. Selective coronary angiography of this right dominant system was difficult due to right brachial access with severe subcalvian artery tortuosity. Despite attempts with multiple catheters, we were not able to engage the LMCA. Sub-optimal images of the RCA demonstrated a probably 60% distal stenosis. 2. Left ventriculography was deferred. 3. Limited resting hemodynamics demonstrated markely elevated systemic systolic pressure. [2169-8-10] 05:40AM BLOOD Hct-27.9* [2169-8-10] 05:40AM BLOOD Glucose-103 UreaN-10 Creat-0.6 Na-137 K-3.7 Cl-98 HCO3-29 AnGap-14 6/29 L heart cath right dominant system. LMCA: nl LAD: 40% fter D1. LCX: mid vessel 50% stenosis at the origin of the OM1. The OM1 had a tubular ostial/proximal stenosis of 70%. RCA: 70% ostial stenosis, a 50% mid segment stenosis and a 90% distal segment stenosis before the PDA/PL bifurcation. 2. Resting hemodynamics reveal mild systemic arterial hypertension. 3. No left ventriculogram performed to reduce contrast load. 4. Despite prolonged attempts it was not possible to recannulate the RCA ostium and the procedure was terminated due to prolonged fluroscopy time. 1. Two vessel coronary artery disease. 2. Mild systemic arterial hypertension [2169-8-11] 03:58AM BLOOD WBC-13.9# RBC-3.63 Hgb-10.9* Hct-31.1* MCV-86 MCH-30.1 MCHC-35.0# RDW-15.7* Plt Ct-213 [2169-8-11] 03:58AM BLOOD PT-12.5 PTT-28.0 INR(PT)-1.1 [2169-8-11] 03:58AM BLOOD Glucose-135* UreaN-9 Creat-0.7 Na-134 K-3.6 Cl-103 HCO3-21* AnGap-14 [2169-8-11] 03:58AM BLOOD Calcium-7.0* Phos-3.6 Mg-1.6 [2169-8-14] 06:55AM BLOOD Triglyc-166* HDL-25 CHOL/HD-4.1 LDLcalc-44 [2169-8-15] 05:50AM BLOOD Calcium-7.6* Phos-2.7 Mg-2.1 [2169-8-15] 05:50AM BLOOD Glucose-79 UreaN-23* Creat-0.7 Na-136 K-3.6 Cl-101 HCO3-25 AnGap-14 [2169-8-15] 05:50AM BLOOD Neuts-88* Bands-0 Lymphs-5* Monos-1* Eos-4 Baso-1 Atyps-0 Metas-0 Myelos-1* [2169-8-16] 06:15AM BLOOD PT-12.0 PTT-28.0 INR(PT)-1.0 [2169-8-16] 06:15AM BLOOD Plt Ct-284 [2169-8-16] 06:15AM BLOOD WBC-9.4 RBC-3.58* Hgb-11.0* Hct-31.6* MCV-88 MCH-30.7 MCHC-34.7 RDW-16.5* Plt Ct-284 Brief Hospital Course: Ms. [Known lastname ] is an 86 year old white female with past history of HTN, CAD s/p MI, severe spinal stenosis and AIHA presenting to CCU s/p cath with Hct drop from 26 ->15.5. 1) Cardiac: (a) CAD: Patient underwent catheterizations x 2 as part of pre-operative work-up for surgical intervention for her spinal stenosis. She was found to have 2 vessel disease. Procedures were aborted on both occasions without successful stent placement due to unability to engage the LMCA and prolonged fluoroscopy time, respectively. In lieu of recannulation, she will be medically optimized on ASA and AceI. Continue ASA, as discontinuing would be unlikely to change status of hematoma given long half-life. metoprolol changed to atenolol. lisinopril increased to 20 qd. We are not considering 3rd attempt at cath (b) Rhythm - Maintaining NSR. Beta-blocker dosage was up-titrated as tolerated by BP. (c) Pump - last ECHO demonstrated LV EF 60-65% with marked right and left atrial enlargement. PA pressure 35. Patient on lisinopril and atenolol 2) Anemia. Patient remained hemodynamically stable s/p 4 units of PRBC's which she received post-cath, hct around 31.6. Large right groin hematoma extends to abdomen and right inner thigh with normal color changes. Pt without clinical indicators for RP bleed. Although hemodynamically stable, her hct continued to trend slightly downwards, and she was electively transfused later in the hospitalization with an additional 1 u PRBC's. Continue to monitor CBC's. She is on folic acid 3) Psuedoaneurysm: Right femoral u/s revealed 1.4 x 1.0 x 0.9 pseudoaneurysm s/p catheterization. Interventional cards aware of it. No intervention necessary at this time. Dr. [Last Name (STitle) 3407] emailed about this. His office will contact the patient regarding the management of the aneurysm. 4) Rash a) Maculopapular Rash - likely secondary to drug reaction, now with coallescing macules over her posterior aspect. Temporal relationship with dose of Plavix given cath lab and with PRN dose of lasix make these the two most likely culprits (although family says she previously tolerated lasix). Might also be delayed reaction to dye. Continue Atarax for pruritis and Sarna lotion and hydrocortisone lotion. Avoid diphenhydramine given potential for AMS in geriatric patients. b) Vesicular rash - over right buttock and flank. Consider desquamation secondary to large hematoma vs. radiation burn vs. herpes zoster. Dermatology consulted on [8-15]. They suspected her to have Herpes zoster.DFA was ordered and was negative. 4.) Cellulitis of left foot: keflex for 7 days. 5.) AIHA - Continued prednisone 7.5 qday. 6.) Code status: Full code. Medications on Admission: Ultram 50mg q6 and 25mg PRN for break through Senna 2tabs qhs Senna 30cc every other day ECASA 325mg daily Cardizem CD 240mg daily Folic Acid 1mg daily Imdur 30mg daily Prednisone 7.5 mg daily Colace 100mg [Hospital1 ] Zantac 150mg [Hospital1 ] Tylenol 975mg q6 OTC Simbalta 60mg daily Oscal w/D 500mg tid Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: Thirty (30) ML PO QID (4 times a day) as needed for indigestion. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Prednisone 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Hydroxyzine HCl 10 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:28 Tablet(s) Refills:0 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. Disp:1 Refills:0 12. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [Hospital1 ] (2 times a day). Disp:1 Refills:2 13. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 15. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual q5 min prn as needed for chest pain. 16. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 17. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 18. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Keflex 500 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 5 days. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Hypertension Autoimmune Hemolytic Anemia CAD Depression urinary retention spinal stenosis with L4 fracture Discharge Condition: Stable Discharge Instructions: Please take all medications as prescribed If you have chest pain, shortness of breath, dizziness, palpitations,fever, cough, pain in abdomen please call the doctor on call. Followup Instructions: Please call your PCP Dr [Last Name (STitle) 2539] at [Telephone/Fax (1) 105093] to make a follow up appointment. Please do a chem 10 three days after the discharge as patient on acyclovir. Please keep your appointment with RADIOLOGY (Phone:[Telephone/Fax (1) 1125]) Date/Time:[2169-10-2] 2:30 Please keep your appointment with [Doctor First Name 475] [Initials (NamePattern4) ] [Last Name (NamePattern4) 474], M.D., Cardiology (Phone:[Telephone/Fax (1) 1989]) Date/Time:[2170-1-5] 2:40 You will get a call from Dr[Name (NI) 1720] office regarding the surgery for the aortic aneurysm. Completed by:[2169-8-17]	[ "E935.9", "682.7", "998.12", "709.8", "283.0", "311", "412", "693.0", "724.02", "285.1", "401.9", "E947.9", "300.00", "997.2", "441.4", "414.01", "733.09", "442.3" ]	icd9cm	[ [ [] ] ]	[ "99.04", "37.22", "88.56" ]	icd9pcs	[ [ [] ] ]	12557, 12629	7772, 10476	524, 1679	12779, 12788	5345, 7749	13009, 13664	4312, 4431		10841, 12534		12650, 12758		10502, 10818			12812, 12986									4446, 5326																								174, 486										1707, 3268															3290, 3906	3922, 4296
26,103	188,628	22071	Discharge summary	report	Admission Date: [2132-2-27] Discharge Date: [2132-3-8] Date of Birth: [2054-3-30] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: Mr. [Known lastname ] is a 77 year old man who is undergoing a preoperative evaluation for a laryngeal tumor biopsy. During a routine evaluation he had electrocardiogram changes that lead him to a stress test which was positive and then lead to cardiac catheterization that showed two vessel disease with a 70 percent left anterior descending coronary artery lesion, a 90 percent diagonal lesion and 100 percent circumflex coronary artery lesion and an ejection fraction of 50 percent. The patient had his laryngeal biopsy followed by six weeks of radiation therapy and returned as a postoperative admit for coronary artery bypass grafting. The cardiac catheterization was done in [2131-8-12]. He underwent an echocardiogram in [2131-7-12] that showed near 55 percent with mild mitral regurgitation and mild inferior wall hypokinesis. PAST MEDICAL HISTORY: The patient's past medical history is significant for hypertension, hyperlipidemia, cerebrovascular accident in [2131-5-12], paroxysmal atrial fibrillation, second degree heart block, coronary artery disease, laryngeal cancer status post radiation therapy. PAST SURGICAL HISTORY: Past surgical history is significant for appendectomy and laryngeal biopsy. MEDICATIONS: The patient's medications prior to admission include aspirin 325 once daily, Lipitor 40 once daily, Norvasc 5 once daily, isosorbide 30 once daily, atenolol 12.5 once daily. ALLERGIES: The patient states no known drug allergies. FAMILY HISTORY: Family history is significant for a father who had an myocardial infarction in his 80s. SOCIAL HISTORY: The patient has a remote tobacco history, quit in [2092], prior to which she had 120 pack year history. The patient lives with his daughter and has rare alcohol use. PHYSICAL EXAMINATION: At preoperative testing, height 5 feet 8 inches, weight 132 pounds. General, in no acute distress. Skin is without lesions. Head, eyes, ears, nose and throat, pupils equal, round and reactive to light. Extraocular movements intact. Anicteric. Noninjected. Neck is supple with a soft mass on the front of his neck, no lymphadenopathy, no bruits. Chest is clear to auscultation. Heart, S1 and S2 with an S4, no murmur, rubs or gallops. Abdomen: Soft, nontender, nondistended with normoactive bowel sounds. Extremities are warm and well perfused with no edema or varicosities. Neurologic is alert and oriented times three, moves all extremities and follows commands. Nonfocal examination. Pulses are 1plus throughout. HOSPITAL COURSE: As stated previously the patient was a direct admission to the Operating Room, please see the operating room report for full details. In summary, the patient had a coronary artery bypass graft times four with a left internal mammary artery to the diagonal, saphenous vein graft to the left anterior descending coronary artery, saphenous vein graft to obtuse marginal and saphenous vein graft to posterior descending coronary artery. Additionally, the patient had a resection of an aortic valve lesion which turned out to be consistent with Lambl's excrescence. The patient's bypass time was 102 minutes with a cross clamp time of 86 minutes. He tolerated the operation well and was transferred from the Operating Room to the cardiothoracic Intensive Care Unit. At the time of transfer, the patient was atrially paced at 78 beats/minute with a mean arterial pressure of 69 and a central venous pressure of 2. He atherosclerotic heart disease Neo-Synephrine at 0.5 mcg/kg/min and Propofol at 20 mcg/kg/min. The patient did well in the immediate postoperative period. His anesthesia was reversed. Sedation was discontinued. He was weaned from the ventilator and successfully extubated. On postoperative day Number 1, the patient continued to do well. He was hemodynamically stable requiring only nitroglycerin to maintain an adequate blood pressure. The patient was begun on beta blockade as well as diuretics. His nitroglycerin infusion was weaned, and given his prior history of heparin block, the electrophysiology service was consulted and the patient remained in the Cardiothoracic Intensive Care Unit. On postoperative day Number 2, the patient had atrial fibrillation which he was successfully cardioverted out of. Additionally, the patient was begun on heparin for his atrial fibrillation. On postoperative day Number 3, the patient's Swan-Ganz catheter as well as chest tubes was removed. He was noted to have intermittent periods of atrial fibrillation. He was again cardioverted and started on Amiodarone following cardioversion. The decision was made at that time to keep the patient in the Cardiothoracic Intensive Care Unit as it was anticipated that the patient would need a pacemaker prior to discharge given his slow ventricular response after cardioversion. On postoperative day Number 5, the patient was brought to the Cardiac Catheterization Laboratory where he underwent placement of a permanent pacemaker. Please see PP report for full details. Following placement of the pacemaker the patient was transferred to Far 2 for continuing postoperative care and cardiac rehabilitation. Once on the floor, the patient was progressing slowly from his coronary artery bypass grafting as well as pacemaker placement, when on postoperative day Number 6 from coronary artery bypass graft and day Number 1 from pacemaker placement, he was noted to have bloody stool. He was placed on intravenous Protonix and a gastroenterology consult was called. The patient remains hemodynamically stable during this period and his hematocrit also remains stable during this period. Following full prep, the patient underwent colonoscopy on postoperative day Number 8. The colonoscopy showed two benign appearing polyps that were nonbleeding as well as internal hemorrhoids and multiple nonbleeding diverticula in the sigmoid colon. The patient did not undergo polypectomy at that time as he was somewhat anticoagulated due to his atrial fibrillation. He tolerated the procedure well and was transferred back to Far 2. Over the next few days the patient was monitored with serial hematocrits. He remained hemodynamically stable and on postoperative day Number 10, it was decided that the patient was stable and ready to be transferred to rehabilitation for continuing care. At the time of this dictation the patient's physical examination is as follows: Temperature 99, heart rate 69 paced, blood pressure 131/57, respiratory rate 20, oxygen saturation 100 percent on room air. Weight preoperatively 62.1 kg, at discharge 61.5 kg. Laboratory data revealed white count 6.7, hematocrit 27.5, platelets 331, PT 16, INR 1.7 with one additional INR to be checked on the morning of discharge. Sodium 143, potassium 3.5, chloride 111, carbon dioxide 26, BUN 12, creatinine 1.0, glucose 68. Neurologically alert and oriented times three, moves all extremities. Follows commands. Pulmonary, clear to auscultation bilaterally. Cardiac, regular rate and rhythm, sternum is stable, incision with staples, without erythema or drainage. Abdomen is soft, nontender with normoactive bowel sounds. Extremities are warm with no edema. Left leg incision from endoscopic harvest site with Steri-Strips clean and dry. Left shoulder incision from pacemaker implantation with Steri-Strips, clean and dry with dry sterile dressing. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: He is to be discharged to the [Hospital1 3494] TCU. DISCHARGE DIAGNOSIS: Status post coronary artery bypass grafting times four with left internal mammary artery to the diagonal, saphenous vein graft to the left anterior descending coronary artery, saphenous vein graft to obtuse marginal and saphenous vein graft to posterior descending coronary artery. Second degree heart block status post permanent pacemaker, Medtronics Sigma STR303. Status post gastrointestinal bleed and colonoscopy. Paroxysmal atrial fibrillation. Laryngeal carcinoma status post radiation therapy. Hypertension. Hypercholesterolemia. Transient ischemic attack. FOLLOW UP: The patient is to have follow up with Dr. [Last Name (STitle) ] in four weeks, follow up with Dr. [Last Name (STitle) ] in the Device Clinic in one week. Follow up with Dr. [Last Name (STitle) ] or Dr. [First Name (STitle) 572], Gastroenterology Service on [5-14], at 9:30. DISCHARGE MEDICATIONS: 1. Colace 100 mg b.i.d. 2. Aspirin 81 mg once daily. 3. Percocet 5/325 one to two tablets q. 4-6 hours prn. 4. Metoprolol 25 mg b.i.d. 5. Prilosec 40 mg b.i.d. 6. Amiodarone 400 mg once daily times two weeks and then 200 mg once daily. 7. Atorvastatin 40 mg once daily. 8. Lisinopril 10 mg once daily. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1714], [MD Number(1) 1715] Dictated By:[Last Name (NamePattern4) 1718] MEDQUIST36 D: [2132-3-7] 19:21:23 T: [2132-3-7] 20:17:22 Job#: [Job Number 57719]	[ "211.3", "V10.21", "396.3", "285.9", "250.00", "426.13", "455.0", "414.01", "401.9", "427.31" ]	icd9cm	[ [ [] ] ]	[ "99.04", "36.13", "36.15", "37.72", "37.83", "35.11", "99.61", "39.61" ]	icd9pcs	[ [ [] ] ]	7610, 7667						1665, 1754		8593, 9169		7689, 8261			2710, 7554										1325, 1648									8273, 8570					1965, 2692																					164, 1016															1039, 1301	1771, 1942	7579, 7586
28,239	174,102	34521	Discharge summary	report	Admission Date: [2100-8-1] Discharge Date: [2100-8-6] Date of Birth: [2036-5-31] Sex: M Service: SURGERY Allergies: Codeine Attending:[First Name3 (LF) 1384] Chief Complaint: Bleeding liver mass Major Surgical or Invasive Procedure: None History of Present Illness: 64M, known chronic hepatitis/hepatomegaly, presented to [Hospital3 5365] ED 2 days ago with acute onset of abdominal pain and full body discomfort and an episode of "blacking out". Patient was in usual state of health until that time, and went to [Hospital3 5365]. Was hypotensive in the 80s, responded to 2L of IVF. Had some dry heaves, but no nausea/vomitting/ hematemesis. No brbpr or hematochezia. No fevers, chills, sweats, CP or SOB. Reports about 10lb wt loss over the past 2 months. Had hct of 32, got 2U of prbcs. no hct since that time. Past Medical History: Hep C, ?hep B, htn, ptsd, fibromyalgia, emphysema (can walk multiple flights of stairs), fairly clean cath in [3-5] (60% RCA stenosis) Social History: remote h/o of IVDU/cocaine (Denies any currently), no ETOH, 50pk year tobacco, current 1 ppd. Homeless, living with a friend now. Family History: N/C Physical Exam: 98.7 79 99/60 13 99%RA NAD AOx3 RRR CTAB w/ scattered wheezes mild distension, hepatomegaly, tender lower ab only to deep palpation, no signs of varices no c/c/e, +2 distal pulses Pertinent Results: On Admission: [2100-8-1] WBC-11.1* RBC-3.44* Hgb-10.7* Hct-30.8* MCV-90 MCH-31.0 MCHC-34.6 RDW-14.0 Plt Ct-220 PT-12.2 PTT-23.1 INR(PT)-1.0 Glucose-97 UreaN-23* Creat-0.7 Na-137 K-4.4 Cl-105 HCO3-25 AnGap-11 ALT-41* AST-60* AlkPhos-77 TotBili-0.5 Albumin-3.5 Calcium-8.7 Phos-2.6* Mg-2.0 Iron-150 [2100-8-1] calTIBC-252* Ferritn-336 TRF-194* [2100-8-1] HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-POSITIVE HAV Ab-NEGATIVE HCV Ab-POSITIVE [2100-8-1] CEA-1.1 AFP-13.9* On Discharge: [2100-8-6] WBC-6.7 RBC-3.87* Hgb-12.3* Hct-34.3* MCV-89 MCH-31.7 MCHC-35.7* RDW-14.2 Plt Ct-249 PT-12.7 PTT-26.3 INR(PT)-1.1 Glucose-89 UreaN-12 Creat-0.6 Na-137 K-4.3 Cl-101 HCO3-29 AnGap-11 ALT-46* AST-56* AlkPhos-120* TotBili-1.2 Brief Hospital Course: 64 y/o male initially transferred from OSH to the SICU. Triple phase CT scan was performed on his abdomen. -Segment VIII 4.0 x 3.9 x 4.0-cm heterogeneously enhancing liver mass is concerning for a hepatoma. -No change in hemoperitoneum, with no evidence of active extravasation. -Subtle focus of arterial enhancement in segment VI, also concerning for malignancy. -Tumor/ thrombus in middle hepatic vein. -Mesenteric stranding and thick walled colon, likely from third spacing. Varices. He received 3 units of RBC's for the bleeding from the right lobe of the liver. His Hct remained stable following the transfusions. Patients' main complaint was pain, most notably in shoulders and upper back. He was initially given oxycodone with fair effect and switched to dilaudid which appeared to provide better pain relief. Patient was seen by the GI service while in house, and an attempt was made to obtain EGD. He was unable to tolerate conscious sedation, and in fact became agitated with administration of Versed. The patient will be scheduled for an outpatient EGD and potentially for liver biopsy to assess status of the hepatitis C and evidence of cirrhosis as this has not been done in the past. Patient underwent nuclear bone scan which reports: No scintigraphic evidence of osseous metastases. Degenerative changes in the lower lumbar spine, mid thoracic spine, right sternoclavicular joint and right knee. He was also seen by Hepatology service who will follow, and if patient wishes to pursue interferon therapy at some point, they will become involved. Patients case was presented at Radiologic rounds and the decision was made to offer patient chemoembolization as this was not felt to be resectable. He will return to Dr [Last Name (STitle) 9411] clinic in 2 weeks and also has GI follow-up scheduled. Medications on Admission: atenolol 50', percocet, trazadone, omeprazole Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Hemoperitoneum s/p bleeding mass in liver concerning for hepatoma Discharge Condition: fair Discharge Instructions: Please call Dr.[Name (NI) 670] office [Telephone/Fax (1) 673] if you have abdominal pain, fever more than 101, chills, nausea, vomiting, blood in stool Do not lift anything heavier than a gallon of milk, no heavy labor until cleared by Dr [First Name (STitle) ] Followup Instructions: Follow up with Dr. [First Name (STitle) ] [Telephone/Fax (1) 673] on [8-20] at 3:20 [Name6 (MD) 1948] [Last Name (NamePattern4) 1949], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2100-8-26] 11:00 EUS (ST-4) GI ROOMS Date/Time:[2100-8-26] 11:00 Completed by:[2100-8-6]	[ "785.59", "155.0", "492.8", "307.9", "305.60", "573.8", "568.81", "453.0", "401.9", "V60.0", "309.81", "305.1", "070.70", "456.8", "729.1" ]	icd9cm	[ [ [] ] ]	[ "99.04" ]	icd9pcs	[ [ [] ] ]	4453, 4459	2175, 3994	285, 292	4569, 4576	1425, 1425	4898, 5204	1204, 1209		4091, 4430		4480, 4548		4021, 4068			4600, 4875									1224, 1406																1914, 2152								226, 247										320, 877									1439, 1900						899, 1040	1056, 1188
83,427	194,377	3515	Discharge summary	report	Admission Date: [2113-1-30] Discharge Date: [2113-2-7] Date of Birth: [2037-8-9] Sex: F Service: SURGERY Allergies: Fentanyl Attending:[First Name3 (LF) 2534] Chief Complaint: s/p fall pneumothorax abdominal pain Major Surgical or Invasive Procedure: Left tube thoracostomy and resection of cecum and terminal ileum with an ileal ascending colostomy. History of Present Illness: Ms. [Known lastname ] is a 75 year old woman who presented to the ER last night with a small left hemopneumothorax and fractures of left ribs [5-25] after sustaining a fall to the left lateral chest on a coffee table two days prior. In addition the patient was noted to have a 9cm cecum that is malpostitioned as well as malpositioned small bowel. At that time she had no abdominal complaints. However, over the course of the day today she began to develop abdominal distention and nausea. An NGT was placed which put out 400 cc coffee ground material. She is passing gas but has had no bowel movement since. She reports diffuse pain patricularly with palpation. She is vomiting around NGT despite proper function. Past Medical History: HTN PVD s/p R popliteal stent osteoporosis breast ca s/p right mastectomy with TRAM reconstruction olecranon fracture s/p repair (15 yrs ago) Social History: No tobacco, etoh, drugs, lives alone Family History: non-contributory Physical Exam: Upon Admission: A/O x 3 NAD Uncomfortable NCAT No icterus No jaundice RRR No murmurs CTAB No crackles, wheezes, rhonchi Abd massively distended and tympanetic and quite tender, No hernias, Guaiac negative with some hard stool in rectal vault, pt vomits with palpation Pertinent Results: [2113-1-30] 03:58PM BLOOD WBC-11.6# RBC-4.24 Hgb-13.4 Hct-38.2 MCV-90 MCH-31.7 MCHC-35.2 RDW-13.2 Plt Ct-234 [2113-1-31] 09:10PM BLOOD WBC-17.6# RBC-3.56 Hgb-11.7* Hct-32.6* MCV-92 MCH-32.8* MCHC-35.8* RDW-12.5 Plt Ct-208 [2113-2-1] 01:22AM BLOOD WBC-10.6 RBC-3.71* Hgb-12.0 Hct-33.8* MCV-91 MCH-32.4* MCHC-35.6* RDW-12.8 Plt Ct-187 [2113-2-1] 07:35PM BLOOD WBC-8.4 RBC-3.26* Hgb-10.6* Hct-30.1* MCV-92 MCH-32.4* MCHC-35.1* RDW-13.0 Plt Ct-198 [2113-2-2] 03:17AM BLOOD WBC-8.5 RBC-2.89* Hgb-9.2* Hct-27.2* MCV-94 MCH-31.9 MCHC-33.9 RDW-12.8 Plt Ct-216 [2113-2-2] 07:58AM BLOOD WBC-9.0 RBC-3.13* Hgb-10.2* Hct-29.2* MCV-93 MCH-32.6* MCHC-34.9 RDW-12.4 Plt Ct-242 [2113-2-3] 03:08AM BLOOD WBC-8.8 RBC-3.19* Hgb-10.2* Hct-29.1* MCV-91 MCH-32.0 MCHC-35.1* RDW-12.1 Plt Ct-264 [2113-1-30] 03:58PM BLOOD Glucose-118* UreaN-15 Creat-0.8 Na-137 K-4.0 Cl-92* HCO3-34* AnGap-15 [2113-1-31] 09:10PM BLOOD Glucose-143* UreaN-30* Creat-0.9 Na-130* K-3.8 Cl-87* HCO3-34* AnGap-13 [2113-2-1] 01:22AM BLOOD Glucose-149* UreaN-29* Creat-0.8 Na-129* K-3.7 Cl-92* HCO3-25 AnGap-16 [2113-2-1] 07:35PM BLOOD Glucose-126* UreaN-18 Creat-0.7 Na-133 K-4.8 Cl-96 HCO3-29 AnGap-13 [2113-2-2] 03:17AM BLOOD Glucose-123* UreaN-21* Creat-1.1 Na-132* K-4.4 Cl-97 HCO3-29 AnGap-10 [2113-2-2] 07:58AM BLOOD Glucose-171* UreaN-20 Creat-1.0 Na-131* K-3.6 Cl-95* HCO3-29 AnGap-11 [2113-2-3] 03:08AM BLOOD Glucose-88 UreaN-16 Creat-0.9 Na-134 K-3.2* Cl-96 HCO3-30 AnGap-11 [2113-2-4] 01:40AM BLOOD Glucose-110* UreaN-16 Creat-0.7 Na-133 K-4.0 Cl-96 HCO3-34* AnGap-7* [2113-2-4] 06:20AM BLOOD Glucose-101 UreaN-15 Creat-0.7 Na-136 K-4.1 Cl-96 HCO3-34* AnGap-10 [2113-1-31] 09:10PM BLOOD Calcium-9.0 Phos-3.0 Mg-2.1 [2113-2-1] 01:22AM BLOOD Calcium-8.0* Phos-3.0 Mg-1.9 [2113-2-1] 07:35PM BLOOD Calcium-8.0* Phos-1.9* Mg-2.5 [2113-2-2] 03:17AM BLOOD Calcium-7.4* Phos-2.2* Mg-2.4 [2113-2-2] 07:58AM BLOOD Albumin-3.0* Calcium-7.4* Phos-2.2* Mg-2.4 [2113-2-3] 03:08AM BLOOD Calcium-7.7* Phos-2.2* Mg-2.5 [2113-2-4] 01:40AM BLOOD Calcium-7.9* Phos-2.1* Mg-2.4 [2113-2-4] 06:20AM BLOOD Calcium-7.8* Phos-2.4* Mg-2.4 CT Torso [1-30]: IMPRESSION: 1. Moderate left hydropneumothorax, small pneumomediastinum, and massive subcutaneous air in the left chest wall. Air also dissects up into the neck. 2. Mildly displaced segmental rib fractures (left seventh, eighth, and ninth) with possibility of flail chest. Nondisplaced first left rib fracture. 3. Cecum measuring to 9 cm and malpositioned/non rotated with no small-bowel obstruction; correlate clinically. Small bowel nonrotated and malpositioned in the right lower quadrant. 4. Right lower lobe nodule which may be infectious/inflammatory in etiology, although neoplasm cannot be ruled out; recommend followup chest CT in six months. 5. Extensive vascular disease. Atherosclerosis and aneurysmal dilatation of the SMA. 6. Compression fracture of T10, age indeterminant; if clinically appropriate, can consider edema-sensitive MR [First Name (Titles) ] [Last Name (Titles) 11197] acuity. KUB [1-31]: IMPRESSION: 1. Significantly dilated loops of colon with a large air-fluid level suggesting either sigmoid volvulus or cecal bascule with volvulus. 2. Significant subcutaneous air seen in the left upper abdominal wall, consistent with the known history of left chest trauma. Portable CXR [2-2]: IMPRESSION: Retrocardiac atelectasis without evidence of pneumonia. Small bilateral pleural effusions and extensive subcutaneous air. Pathology: Terminal ileum, cecum, and right colon, segmental resection: 1. Mucosal and focal transmural necrosis with cecal perforation, consistent with ischemia. 2. Unremarkable distal colonic and proximal ileal resection margins. 3. Appendix, no diagnostic abnormalities recognized. 4. One lymph node, no diagnostic abnormalities recognized. Brief Hospital Course: Mrs. [Known lastname ] was admitted to the Thoracic Surgery service after falling and complaining of SOB and was found to have a left hemopneumothorax. Shortly thereafter, she c/o abdominal pain and increased distention. An NGT was placed and a KUB was obtained. She was found to have a cecal volvulus and brought emergently to the OR with the general surgery service. She tolerated her bowel resection well. A chest tube was also placed in the OR. She recovered in the PACU without acute events and was transferred to the floor. Her chest tube and NGT were removed and she was advanced to a sips diet and placed on her home meds. On the evening of [2-1], she was "triggered" for tachycardia and hypotension, and low UOP. She was transferred to the ICU for closer management. She remained in the ICU for roughly 24 hours before transferring back to the floor in stable condition. On [2-4] her foley catheter was removed and she began tolerating a clear liquid diet. She was ambulating and her pain was well controlled with PO pain meds. On [2-5] and [2-6] she was having a difficult time tolerating a regular diet, becoming mildly distended. On [2-7] she had a bowel movement and was tolerating a full regular diet. She was discharged home in good condition. Medications on Admission: 1. Verapamil 240 mg Cap,24 hr Sust Release Pellets Sig: Two (2) Cap,24 hr Sust Release Pellets PO once a day. 2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO every other day. 3. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Discharge Medications: 1. Verapamil 240 mg Cap,24 hr Sust Release Pellets Sig: Two (2) Cap,24 hr Sust Release Pellets PO once a day. 2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO every other day. 3. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:30 Tablet(s) Refills:0 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 10 days: take while taking narcotics. Hold for loose stools. Disp:20 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Cecal volvulus left hemopneumothorax Discharge Condition: Stable. Staples in place. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. Other: Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. Avoid driving or operating heavy machinery while taking pain medications. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. Followup Instructions: Please follow up with Dr. [Last Name (STitle) ] in 1 week to have your staples removed and for your intial follow up. Call his office ASAP to make your appointment. ([Telephone/Fax (1) 1483]. You also have the following appointments: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4286], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2113-2-8] 11:00 Provider: [Name10 (NameIs) 706] Phone:[Telephone/Fax (1) 327] Date/Time:[2113-3-20] 9:10 Provider: [Name10 (NameIs) ] [First Name8 (NamePattern2) 1243] [Name8 (MD) ], M.D. Date/Time:[2113-4-17] 8:40 Completed by:[2113-2-7]	[ "733.00", "518.0", "401.9", "V10.3", "958.7", "788.5", "560.2", "276.52", "443.9", "860.0", "540.0", "807.03", "458.9", "E885.9" ]	icd9cm	[ [ [] ] ]	[ "45.72", "34.09" ]	icd9pcs	[ [ [] ] ]	7972, 7978	5659, 6949	303, 405	8059, 8087	1724, 5636	9282, 9932	1402, 1420		7318, 7949		7999, 8038		6975, 7295			8111, 9259									1435, 1437																								227, 265										433, 1165									1451, 1705						1187, 1331	1347, 1386
53,679	195,598	35373	Discharge summary	report	Admission Date: [2113-2-20] Discharge Date: [2113-3-6] Date of Birth: [2033-11-18] Sex: M Service: MEDICINE Allergies: Quinolones / Ciprofloxacin Attending:[First Name3 (LF) 12077] Chief Complaint: CC:[CC Contact Info 80635] Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 79 yo man with PMH of CAD, s/p stents, RA, Glaucoma, prostate enlargement, basal cell ca who was found to have right occipital [Doctor Last Name 534] intraventricular hemorrhage at OSH. Has been having some mild confusion off/on for the last week or so. Also some nonspecific blurriness of his vision in all fields, which his family attributed to cataracts and dirty glasses. Then had a mild to moderate headache at 5pm. Was also noting some difficulty finding things at that time. Then around 7 pm felt that headache was much worse. Became progressively more disoriented and HA worsened. Developed nausea. Was taken to OSH. CT scan showed right occipital hemorrhage into the ventricle, and pt was transferred to [Hospital1 18] ROS: no headaches prior to today. vision changes as described above. Some gait instability today. Also complains of some difficulty swallowing. Past Medical History: HTN CAD s/p stents Rheumatoid arthritis Glaucoma prostate enlargement basal cell ca All: Cipro/levoflox: anaphylaxis Social History: Patient was previously functional. Retired from pharmaceutical industry. Lives at home with wife; three children live close by. Family History: Sister died of bladder ca. Father had MI at 47. Physical Exam: EXAM ON ADMISSION O: T: 97.4 BP: 159/67 HR: 51 R 16 O2Sats 99RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: [2-27] EOMs: intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date but mildly confused and initially does not get month or date correct. Language: naming intact, repeats and follows commands. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Dense left homonymous hemianopia. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [5-2] throughout. No pronator drift Sensation: Intact to light touch bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 2 1 Left 3 2 2 3 1 Toes down right, up left Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Pertinent Results: HEAD CT W/O CONTRAST [2113-2-20]: Large right-sided hemorrhage, predominantly centered within the right occipital [Doctor Last Name 534] with adjacent mass effect on the brain parenchyma. There is mild leftward subfalcine herniation and dilatation of the right temporal [Doctor Last Name 534]. MRI with contrast will be helpful to evaluate for possible underlying lesion or vascular malformation CTA HEAD W&W/O C & RECONS [2113-2-20]: 1. Unchanged appearance of right-sided intraparenchymal hemorrhage with extension into the occipital [Doctor Last Name 534] of the lateral ventricle. Mild mass effect, indicated by slight midline shift, is unchanged. 2. No evidence for aneurysm or AVM or other vascular abnormality. However, a compressed AVM, secondary to mass effect, with resultant tamponade cannot be excluded as source of bleed. If this is of clinical concern, repeat CTA when mass effect has decreased, or catheter angiography, could be performed. CT HEAD W/O CONTRAST [2113-2-21]: No significant interval change in the intraventricular hemorrhage; no new hemorrhage. CT HEAD W/O CONTRAST [2113-2-23]: Unchanged appearance of right occipital hemorrhage. Slightly increased edema, but no significant change in degree of mass effect. Ventricles are unchanged in size with no transependymal edema to suggest hydrocephalus. CT HEAD W/O CONTRAST [2113-2-26]: No change in large right occipital hemorrhage extending into right lateral ventricle. Surrounding edema. No new site of hemorrhage. Slight decrease in degree of blood in left lateral ventricle LE Ultrasound [2113-2-27]: No evidence of DVT seen in either lower extremity. CT head w/o contrast [2113-3-3]: 1. No significant change in the size and appearance of the large right temporal intraparenchymal and right lateral ventricular hemorrhage. 2. No new hemorrhage. Please see above details. Admission labs: [2113-2-20] 01:00AM GLUCOSE-145* UREA N-19 CREAT-0.9 SODIUM-140 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-30 ANION GAP-12 [2113-2-20] 01:00AM WBC-11.2* RBC-4.29* HGB-14.4 HCT-41.8 MCV-97 MCH-33.5* MCHC-34.4 RDW-13.9 [2113-2-20] 01:00AM PT-12.4 PTT-27.3 INR(PT)-1.0 Blood and urine cultures: negative Discharge labs: [2113-3-4] 07:50AM BLOOD WBC-7.9 RBC-4.18* Hgb-14.0 Hct-40.4 MCV-97 MCH-33.6* MCHC-34.7 RDW-13.3 Plt Ct-370 [2113-3-5] 07:15AM BLOOD Glucose-89 UreaN-21* Creat-0.7 Na-136 K-4.2 Cl-98 HCO3-27 AnGap-15 [2113-2-21] 02:47AM BLOOD VitB12-606 Folate-14.4 [2113-2-21] 02:47AM BLOOD TSH-1.4 [2113-2-28] 12:50PM BLOOD Cortsol-39.5* Brief Hospital Course: Mr. [Known lastname ] was admitted with R occipital hemorrhage into the ventricles and placed in the ICU. On admission, pt had gross left homonymous hemianopsia, but otherwise non-focal exam. Anticonvulsants were started. CTA was performed to rule out any vascular anomalies. Swallow evaluation was performed, and pt was placed on thin liquids with regular solids with strict 1:1 supervision. On [2-21], the pt's mental status declined. CT head demonstrated no significant changes. Geriatrics was consulted to assist in proper medication choice due to delirium. Keppra was discontinued, and dilantin started. Full infectious workup was performed. On [2-22], the pt was transferred to the step-down unit. PT/OT were consulted and recommended acute rehabilitation. Due to episode of hypotension on [2-25], an EKG was performed, and pt was ruled out with cardiac enzymes x 3 q 8 hours which was negative. Due to pt's poor consumption, nutrition was consulted and calorie counts were performed. He continued with left sided neglect and left sided field cut. Pt was transferred to medicine on [2-27]. 1. Intraventricular hemorrhage: Patient continued to have delirium without agitation. After discussing the matter with neurosurgery, his dilantin was stopped. Repeat head CT on [3-3] showed no change. It was felt that he is most likely delirious from the irritation of the blood in his ventricle, and that it will take many weeks for the blood to be reabsorbed. His ASA 81mg daily was stopped in the setting of his IVH. Per neurosurgery, would restart ASA 2. Hypertension: His medications were adjusted to keep BP <160 during hospitalization. His metoprolol was increased to 100mg [Hospital1 ], clonidine was increased to 0.2mg TID, and HCTZ was stopped in the setting of hyponatremia. 3. Fevers: Patient had low grade fevers on [2-26] and [2-27]. A full infectious work up was negative, and the fevers were attributed to his bleed. Fevers resolved by the time of discharge. 4. Hyponatremia: Pt developed Hyponatremia secondary to SIADH. Diuretics were discontinued and other etiologies were ruled out. Hyponatremia was treated with fluid restriction of 1200cc per day and had resolved by discharge. 6. Rash: Blanching papular rash developed on back thought secondary to contact dermatitis since patient has sensitive skin. Rash improved with steroid cream. 7. Rheumatoid arthritis: His methotrexate and leucovorin were stopped due to drug interactions with dilantin. At the time of discharge, these medications had not yet been restarted. We advise that the patient see his rheumatologist as an outpatient to coordinate restarting his meds; the rheumatologist is aware that they are currently held: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) ]. The patient was put on standing tylenol to help with any pain. 8. h/o Coronary artery disease s/p stents: ASA held as above. Continued on beta blocker, ACE I and simvastatin. Medications on Admission: Enalapril 40 mg daily Clonidine 0.1 mg [Hospital1 ] ASA 81 daily (last dose friday) Doxasozyn 4 mg [Hospital1 ] Lopressor 25 mg HCTZ 12.5 mg Simvastatin 20 mg Methotrexate 20 mg Q week Leukovorin 5 mg Q week. Discharge Medications: 1. Enalapril Maleate 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 2. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). Disp:1 bottle Refills:0 4. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). Disp:240 Tablet(s) Refills:0 6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:0 7. Triamcinolone Acetonide 0.025 % Cream Sig: One (1) Appl Topical DAILY (Daily). Disp:1 tube Refills:0 Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Primary: Intraventricular Hemorrhage Secondary: Delirium, Hypertension, Hyponatremia, Coronary artery disease, Rheumatoid arthritis Discharge Condition: Neurologically stable Discharge Instructions: You were diagnosed with a stroke. We found an intraventricular hemorrhage on CAT scan. You did not need invasive treatment because the bleed was stable. During your hospitalization, you had high blood pressure, a fever, low sodium levels, and became confused. Your blood pressure, fever, and sodium levels gradually improved. However, you continued to be confused during your hospitalization. Please take all medications are directed. The following medication changes were made: Please follow up with all outpatient appointments. You have an appointment with Dr. [First Name (STitle) ] on Thursday, [4-6]. You will also obtain a head CT before your appointment. Please call your doctor or return to the emergency room if you experience any of the following: ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy 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. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. ?????? Fever, chest pain, shortness of breath, or any other concerning symptoms Followup Instructions: Follow up with Dr. [First Name (STitle) ] ([Telephone/Fax (1) ]) on Thursday, [4-6]. You will first obtain a head CT on Thursday, [4-6] at 11:30 AM at the [Location (un) 591] Radiology Office. Then, at 1:00 PM you will see Dr. [First Name (STitle) ] in his office at the [Hospital ] Medical Building, [Hospital Unit Name 18400].	[ "780.60", "431", "414.01", "788.20", "293.0", "600.01", "253.6", "692.9", "714.0", "277.30", "V45.82", "368.46", "599.70", "348.4", "401.9" ]	icd9cm	[ [ [] ] ]	[ "96.6" ]	icd9pcs	[ [ [] ] ]	9658, 9728	5587, 8625	318, 324	9904, 9928	2972, 4872	11183, 11548	1559, 1609		8892, 9635		9749, 9883		8651, 8869			9952, 11160		5220, 5564							1624, 1890																								249, 280										352, 1256	2150, 2953						4888, 5204				1905, 2134				1278, 1397	1413, 1543
857	163,836	24321	Discharge summary	report	Admission Date: [2195-4-27] Discharge Date: [2195-5-4] Date of Birth: [2149-12-15] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1556] Chief Complaint: s/p stab wound to left post axilla,left flank region Splenic injury Major Surgical or Invasive Procedure: s/p exploratory laparotomy s/p splenectomy History of Present Illness: 36 yo male s/p stab wound to left post chest/left flank, unresponsive at scene with intermitt combativeness; intubated at scene. Past Medical History: Hepatitis B & C Social History: Currently homeless; resides in shelter. Has girlfriend who is reportedly pregnant Family History: Noncontributory Physical Exam: Gen- Unresponsive HEENT- EOMI Neck- + JVD; trachea midline, cervial collar in place Chest - + crepitus left chest Cor- tachycardic Abd- flat, soft Skin- diaphoretic Neuro- responds to pain Pertinent Results: [2195-4-27] 11:34PM LACTATE-3.2* [2195-4-27] 11:06PM GLUCOSE-119* UREA N-8 CREAT-0.8 SODIUM-141 POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-21* ANION GAP-16 [2195-4-27] 11:06PM ALT(SGPT)-44* AST(SGOT)-54* ALK PHOS-67 AMYLASE-29 TOT BILI-0.5 [2195-4-27] 11:06PM LIPASE-23 [2195-4-27] 11:06PM ALBUMIN-3.8 CALCIUM-8.7 PHOSPHATE-3.4 [2195-4-27] 11:06PM WBC-7.4 RBC-4.17* HGB-12.8* HCT-36.9* MCV-89 MCH-30.6 MCHC-34.5 RDW-14.2 [2195-4-27] 11:06PM PLT COUNT-177 [2195-4-27] 11:06PM PT-13.0 PTT-28.0 INR(PT)-1.1 Brief Hospital Course: Patient admitted to trauma service; intial chest xray revealed small left pneumothorax, chest tube placed. Patient taken to OR on [2195-4-27] for exploratory lap and splenectomy, he recived 4 units fresh frozen plasma and 2 units packed red cells in OR. Postoperative course stable. Began clear liquids, diet advanced as tolerated. Changed to oral pain medication. Chest tube removed [2195-5-2] without complication. Stab wounds and chest tube site dressed with dry sterile dressings. Ex lap incision staples remained in place, to be taken out at Trauma clinic in 1 week. Prior to discharge was vaccinated w/ pneumovax, meningococc, H.flu vaccinations & given Rx for Amox 3g to take if fever. Medications on Admission: Unknown Discharge Medications: 1. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. Disp:30 Tablet(s) Refills:0 2. Amoxicillin 500 mg Capsule Sig: Six (6) Capsule PO once for fever >101: If you develop fever take all 6 tabs immediately and go to Emergency Department. Disp:6 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: s/p stab wound s/p splenectomy Discharge Condition: Stable Discharge Instructions: Should you develop fever over 101 degrees you should take the 6 Amoxacillin tabs prescribed for you and go to nearest emergency room immediately. Avoid heavy lifting or any strenuous activities for next [2-18] weeks. Be sure to keep your followup appointment with Trauma Clinic. Avoid contact with people who may have a cold. Followup Instructions: Follow up in Trauma Clinic in 2 weeks [Telephone/Fax (1) 6439*], call for an appointment	[ "E966", "865.00", "879.4", "305.60", "860.0", "880.02", "070.70", "V60.0", "070.30", "868.04" ]	icd9cm	[ [ [] ] ]	[ "54.11", "96.71", "41.5", "99.04", "96.04", "34.04" ]	icd9pcs	[ [ [] ] ]	2621, 2704	1551, 2253	382, 427	2778, 2786	981, 1528	3165, 3260	739, 756		2311, 2598		2725, 2757		2279, 2288			2810, 3142									771, 962																								275, 344										455, 585															607, 624	640, 723
27,438	135,159	34129	Discharge summary	report	Admission Date: [2156-6-13] Discharge Date: [2156-6-24] Date of Birth: [2105-10-10] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2901] Chief Complaint: s/p vfib arrest, transferred for continuous EEG monitoring Major Surgical or Invasive Procedure: Extubation, [2156-6-17] History of Present Illness: This is a 50 year old man with known CAD s/p STEMI in [2146] (with LAD stents) and infrequent medical followup since that time who was admitted to [Hospital6 2561] on [2156-6-8] following vfib arrest. History is obtained from the medical records. He reportedly had an unwitnessed (but heard) syncopal event at work around 5:15pm on [6-8]. CPR was started within 2 minutes and 911 was called. AED was applied and a shock was given. On EMS arrival, PEA was noted, and pt was given epi x2, atropine x2 with CPR continued. VF then noted again and shocked x2. Lidocaine 100mg given, follwed by gtt. No BP was obtainable for about 15 minutes. Peripheral dopamine started, after which SBP 108 noted. Pt was intubated en route to the hospital, and sedated with versed. On arrival to the [Last Name (un) 1724] ED, rhythm was sinus tachy 130s-150s with ST elevations V1-V3 noted. . Head CT was negative, and pt was then taken to the cath lab, where multivessel disease was noted. DES x2 placed to LAD (prior stents 100% occluded). Prox RCA was also noted to be chronically occluded with L->R collaterals. IABP was inserted. Arctic Sun cooling protocol was initiated. He was weaned off dopamine and the IABP was discontinued 2 days prior to transfer. . On [6-9] he was noted to have some bleeding from his mouth. ENT evaluated the patient and did not see any ongoing bleeding. However, hct decreased from around 40 initially to 30 today. . The patient has also been spiking fevers and is currently on vancomycin and ceftazidime for empiric treatment of VAP. He reportedly has had H. flu and pan-sensitive staph growing from sputum. . After re-warming, he has been noted to have LE>UE shaking movements which are concerning for seizure activity in the setting of possible anoxic brain injury. Neuro was consulted and pt was loaded with Keppra. The patient is now transferred to [Hospital1 18] for continuous EEG monitoring. . Currently unable to complete review of symptoms, as pt is intubated and sedated. Medical records note that pt's wife reported pt had L anterior chest pain radiating to his left arm on the night prior to admission, but further details of this history are unavailable at this time. Past Medical History: 1. Coronary artery disease, s/p STEMI in [2146] with stents to LAD 2. HTN 3. SBO/strangulated internal hernia s/p small bowel resection in [8-/2149] Social History: Lives at home with his wife. [Name (NI) 1403] as a graphic artist. Smokes 2ppd. Family History: Noncontributory Physical Exam: VS: T 100.6, BP 131/93, HR 101, RR 24, O2 99% on 50% FiO2 Gen: WDWN middle aged male, unresponsive to verbal or painful stimuli, no spontaneous movements. GCS 3. HEENT: Normocephalic, superficial edema/evidence of trauma, Sclera anicteric. PERRL, but variable baseline diameter. Intermittent inferior deviation and rotational movements of both eyes, mostly coordinated. Fundi could not be visualized. Corneal reflex intact but sluggish, vestibular-ocular movements intact. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 6 cm. CVL in place. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3, no murmurs. Chest: On mechanical ventilation, pressure support. Exam limited by supine positioning, but no crackles, wheeze, rhonchi appreciated. Abd: Positive bowel sounds. Obese, soft, non-distended, No HSM. No abdominial bruits. Rectal tone somewhat diminished. Stool guaiac negative. Ext: No clubbing or cyanosis. Significant upper extremity non-pitting edema, and 1+ lower extremity edeam. Peripheral pulses 2+. UE reflexes 0-1+, Patellar reflexes 3+, no clonus, Babinski with no response. No femoral bruits or hematomas. 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: EKG on arrival to [Hospital1 18] demonstrated sinus rhythm, normal intervals and axes, Q waves of [10-27] mm in V1-V3, and of [1-14] mm in III and aVF, compared with OSH EKG which showed ST elevations in V1-V3. . 2D-ECHOCARDIOGRAM performed on [2156-6-9] demonstrated: This was an extremely technically limited study due to poor echo windows, the patient being intubated, hypothermic and having a balloon pump in. There was no pericardial effusion seen. Overall EF was moderately depressed. There was hypokinesis of the anterior wall, apex and antero septum. Aortic valve is not well visualized. There is mild MR. There is trace TR. Again, no pericardial effusion is seen. IMPRESSION: Moderately depressed EF. No evidence of pericardial effusion. Recommendations made for a repeat echocardiogram for better assessment of LV function when the patient has further stabilized. . CARDIAC CATH performed on [2156-6-8] demonstrated: 1. Severe 2-vessel coronary artery disease with acute and chronic occlusions. 2. Severe left ventricular systolic dysfunction. 3. No significant mitral regurgitation or aortic stenosis. 4. Successful balloon angioplasty and stenting (2 drug eluting stents) of the left anterior descending coronary artery acute proximal occlusion resulted in 0% residual stenosis. 5. Intra-aortic balloon pump placed for hemodynamic support. . [2156-6-12] Head CT: 1. Interval development of small low attenuation focus in the L basal ganglia, which may represent a focus of ischemic injury. 2. Interval development of subcutaneous fluid collections over the R parietal and L temporal bones, which most likely represent hematomas if there is a history of recent trauma. 3. Interval worsening of sinus disease. . OSH LABORATORY DATA: [2156-6-13]: WBC 11.9, Hct 30.9, Plt 198 Na 132, K 3.4, Cl 100, CO2 26, BUN 15, Cr 0.9, glc 103. Ca 7.7, Mg 2.0, Phos 2.9. ALT 68, AST 103, AP 64, TB 0.4, Alb 2.0 . CXR ([6-13] at [Hospital1 ], prelim read): ET tube 7 cm above the carina. Right line high in SVC. Hazy opacity in RLL. . EEG: (prelim read, during rhythmic movements) Slow, low amplitude activity in all leads, no spikes or focal activity. . Brief Hospital Course: # CAD/Ischemia: The patient presented s/p MI with 100% lesion of LAD stented with 2 drug-eluting stents. RCA was occluded but had L to R colaterals; no intervention was undertaken during cath. Echo on [6-14] showed severe anterior, septal, and apical hypokinesis. The patient was started on a beta-[Last Name (LF) 7005], [First Name3 (LF) ], statin, and plavix. . # Pump: The patient had TTE on [6-14] showed EF of 30-35%, severe anterior, septal, and apical hypokinesis. The patient was not anticoagulated with heparin for intraventricular thrombus prophylaxis. He was diuresed with lasix and started on Lisinopril 5mg daily. He was sent home on 20mg lasix daily. . # Rhythm: s/p V-fib arrest, now sinus rhythm, monitored on telemetry. Arrest appears to have been in the setting of MI vs old scar; and he remained in sinus rhythm since AED defibrillation. Given his arrest he underwent an EP study which showed inducible ventricular arrhythmia, and an ICD was placed. He was given 2 days of Keflex post ICD placement. He had no further events on telemetry. He was discharged with follow up in device clinic. . # Neurologic status: Per neuro, there was no evidence for seizure, and EEG showed slow, low amplitude acitivity with no foci. Patient was unresponsive initially, likely due to having been without a blood pressure for 15 minutes with possible anoxic brain injury. He did undergo cooling protocol at the outside hospital. Patient became responsive on HD#3, and has had steady improvement in neurological function since. MRI showed no intracranial process. Neuro followed throughout his course. Pt is expected to have continued improvement in his MS up to 6 months; and will be followed as an outpatinet by Dr [Last Name (STitle) ] [Name (STitle) ] who specializes in anoxic brain injury. . # Respiratory failure: Paitent initially intubated on arrival likely from pulmonary edema, poor mental status and pneumonia. Pt extuabted on hospital day #2 and respiratory status improved; able to oxygenate on room air. . # Fevers/Possible Pneumonia: Spiked fevers at OSH to 101 on cooling protocol. WBC 11-->14. Started on vanco and ceftazidime. Sputum culture from [6-10] at OSH grew MSSA, Haemophilus, but continued to spike fevers, so antibiotics were initially continued. Repeat sputum [6-12] grew Staph from OSH. CXR shows RLL hazy opacity. His antibiotics were thus changed to nafcillin/levo given two cultures and clindamycin was added for aspiration pneumonia. Pts fevers defervesced and he was changed to an oral regiment which included dicloxacillin, levofloxacin and clindaymycin. CXR showed interval improvement. Total abx course 14 days, including 10 days of naf->diclox, levo, and clinda. . # s/p fall: C-spine cleared via clinical evaluation and no evidence of ligamentous injury/spinal cord injury on MRI. . # Anemia: Pts Hct was initially low on admission however it remained stable and trended up throughout his stay. Medications on Admission: aspirin 325 fondaparinux 2.5mg daily capoten 6.25 tid ceftazidime 2g q8h HISS keppra 1000mg [Hospital1 ] lipitor 80mg hs metoprolol 25mg qid plavix 75 mg daily protonix 40mg IV daily artificial tears versed gtt vancomycin 1250mg q12h Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily): Total dose should be 125mg daily (in the morning). Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day: Take 1 tablet each morning; total dose of Toprol XL is 125mg daily. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 7. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary diagnosis: - Coronary artery disease Secondary diagnosis: - Ventricular arrhythmia - Cognitive impairment Discharge Condition: Stable, ambulating without difficulty. Discharge Instructions: You were transferred here after being admitted at another hospital after collasping at work. You were able to be successfully extubated. You had a defibrillator (ICD) placed to prevent any further cardiovascular collapses secondary to your heart arrhythmia. You have evidence of some cognitive impairment, and will need to follow up closely with neurologist. . Please contact your cardiologist, primary care physician, [Name10 (NameIs) ] go to the emergency room if you experience any chest pain, palpitations, difficulty breathing, dizziness, fevers, firing of your ICD, or other concerning symptoms. . You have been started on a number of medications. It is very important to continue these medications unless directed by cardiologist. Your Plavix and Aspirin are extremely important, as you are at risk for another heart attack or death if you stop these. Followup Instructions: Please follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in the department of behavioral neurology at an appointment made for you on [7-8] at 10:30 AM. His office is located in [First Name4 (NamePattern1) 40231] [Last Name (NamePattern1) ], [Location (un) ], [Apartment Address(1) ], [Hospital Ward Name 516] (not in the [Hospital Ward Name 23] Building). The number for the clinic is ([Telephone/Fax (1) 1703]. . You should follow up at a cardiology appointment made for you with Dr [Last Name (STitle) ]. You have an appointment on [7-22] at 10:20am. . You will also need to follow up with the device clinic to check the functioning of your ICD at an appointment: DEVICE CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2156-7-1] 11:00 Provider: [Last Name (NamePattern4) ]. [First Name11 (Name Pattern1) 275] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Phone:[Telephone/Fax (1) 2934] Date/Time:[2156-7-22] 10:20 [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909]	[ "285.9", "427.1", "401.9", "410.72", "486", "518.81", "V45.82", "414.01", "780.01" ]	icd9cm	[ [ [] ] ]	[ "37.26", "37.94", "96.71", "96.04", "96.6", "38.91" ]	icd9pcs	[ [ [] ] ]	10863, 10921	6620, 9601	376, 405	11079, 11120	4410, 5800	12031, 13194	2956, 2973		9890, 10840		10942, 10942		9627, 9867			11144, 12008									2988, 4391																								278, 338										433, 2657				11008, 11058	5809, 6597			10961, 10987							2679, 2839	2855, 2940
52,814	182,069	45714+58846	Discharge summary	report+addendum	Admission Date: [2110-4-10] Discharge Date: [2110-4-15] Date of Birth: [2039-7-14] Sex: F Service: MEDICINE Allergies: Codeine / Milk Attending:[First Name3 (LF) 13685] Chief Complaint: blurry vision, DKA Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: This is a 70 yo female with DM2, CAD with history of MI, HLD, who presents with a couple of weeks of blurry vision, polydipsia, polyuria (largely drinking juice, soda, and water) seen by PCP today and found to have ketones in urine with critical high blood glucose, transferred for further evaluation to r/o DKA. Patient is admittedly non-compliant as she has run out of glipizide and has not taken it in a week or so, also, she does not take her glargine regularly stating she sometimes falls asleep and forgets to give it. Of note, she does not check her sugars at home, she only evaluates her sugars when she comes to the doctors. [First Name (Titles) ] [Last Name (Titles) ] fever, chills, n/v, abd pain. She admits to diarrhea on and off for weeks, most recently yesterday and this morning. She [Last Name (Titles) ] any orthostatic symptoms. She also admits to the blurry vision, which she states has been ongoing for about 2-3 weeks, and she felt that it was a cold and nothing more. She also admits to polydipsia, polyuria, over the same time course of [2-20] weeks. She also complains of squeezing chest pain, that starts at a ten and decreases over the course of minutes. It does not radiate and has associated shortness of breath. . In the ED, initial VS were: 97.4 72 131/66 18 100% RA. Exam unremarkable, mental status intact. EKG sinus rhythm at 82 bpm. Given 6 units IV insulin with 6 units/hr IV gtt. Given 40 meq KCl PO. Also given 1L NS, plus on 60 meq KCl in NS at 150ml/hr. Will get CXR. No UA yet. Has 2 PIVs. Current VS: 91 117/60 21 100,RA. . On the floor, she is sitting in bed, comfortable with no complaints. She was oriented and otherwise doing well. Past Medical History: Breast tumor(benign) diabetes type II s/p cholecystectomy MI s/p stent in [5-19] anemia hypertension TAH/BSO osteoarthritis osteoporosis right ankle ORIF hemorrhoid PAST SURGICAL HISTORY: Cholecystectomy in [2083]; cardiac stent placement in [2101]; hysterectomy in [2079]; ORIF ankle fracture, right; and skin cancer removed, right nose in [2103]. Social History: She lives alone in [Location 1268]. She is divorced though her ex-husband helps with errands. Her daughter lives nearby and is very involved. -smoke (quit) -etoh - none -drugs - none Family History: Father with cardiac disease, status post MIs, deceased at the age of 70. Mother with asthma, pregnancyinduced. A sister has [Name2 (NI) 97423] is on medication. A brother had CABG x3 and is deceased ataround 65 years of age. An aunt spent a year in the hospital with TB. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 98.2 BP: 117/59 P: 72 R: 16 O2: 100% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, mildly dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi, somewhat distant breath sounds CV: Distant heart sounds, regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mildly tender to palpation, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema DISCHARGE PHYSICAL EXAM: VS: 97.9 105/52 78 18 99% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, mildly dry MM, oropharynx clear Neck: supple CV: RRR, normal S1/S2, no murmers, gallops, rubs, no S3/4 Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi, somewhat distant breath sounds Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, equal DP pulses b/l, no clubbing or cyanosis, 1+ pitting edema b/l Pertinent Results: ADMISSION LABS: [2110-4-10] 12:50PM BLOOD WBC-8.3 RBC-4.30 Hgb-13.7 Hct-39.1 MCV-91 MCH-31.9 MCHC-35.1* RDW-14.1 Plt Ct-291 [2110-4-10] 12:50PM BLOOD Neuts-72.9* Lymphs-21.9 Monos-3.2 Eos-1.3 Baso-0.7 [2110-4-10] 04:17PM BLOOD PT-12.6 PTT-18.4* INR(PT)-1.1 [2110-4-10] 12:50PM BLOOD Glucose-691* UreaN-17 Creat-1.3* Na-132* K-3.0* Cl-87* HCO3-19* AnGap-29* [2110-4-10] 04:17PM BLOOD ALT-15 AST-17 CK(CPK)-34 AlkPhos-118* TotBili-0.5 [2110-4-10] 04:17PM BLOOD CK-MB-1 cTropnT-<0.01 [2110-4-11] 12:44AM BLOOD CK-MB-2 cTropnT-<0.01 [2110-4-11] 04:36AM BLOOD CK-MB-2 cTropnT-<0.01 [2110-4-11] 11:56AM BLOOD CK-MB-2 cTropnT-<0.01 [2110-4-11] 07:52PM BLOOD CK-MB-2 cTropnT-<0.01 [2110-4-10] 04:17PM BLOOD Calcium-8.4 Phos-1.5# Mg-1.0 [2110-4-10] 04:36PM BLOOD Type-[Last Name (un) ] pO2-18* pCO2-32* pH-7.43 calTCO2-22 Base XS--3 IMAGING: CXR [2110-4-10]: Portable AP chest radiograph was compared to [2106-1-7]. The heart size is mildly enlarged, stable. Aorta is slightly tortuous, unchanged. Lungs are essentially clear. There is minimal linear opacity at the left lung base most likely representing area of atelectasis versus scarring. Overall, no acute process has been demonstrated. Cardiac catheterization [2110-4-14]: patent stent in Lcx 60% lesion OM1 LAD 50% mid segment RCA 50% mid segment TTE [2110-4-15]: The left atrium is normal in size. 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. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. 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. Compared with the prior study (images reviewed) of [2107-9-12], due top poor image quality, unable to compare regional LV systolic function. Global LV systolic function remains preserved. Brief Hospital Course: 70 year old with poorly controlled DMII presenting with hyperglycemia and anion gap acidosis in the setting of poor medication compliance, also with atypical chest pain. # DKA: Likely secondary to medication non-compliance in the very poorly controlled diabetes. She denied any other infectious symptoms precluding this admission. She had a lactate of 5.9, and an anion gap of 26 on admission. Her lactate trended down and her gap has closed. She was changed to SQ insulin ?????? she required 126 units of insulin since admission. Started on glargine 50units SQ and covered with ISS, glargine now at 40 units at lunchtime and still on ISS. She will resume her oral diabetes medications, metformin and glipizide, after discharge to rehab. She should have fingersticks monitored at mealtimes and bedtime and uptitrate insulin as needed. # CAD: Has a history of chronic chest pain, with chest pain morning of [4-11]. She was treated with ASA, atorvastatin 80 for concern for ACS and 2 SL nitro tabs, and 5mg of metoprolol IV that caused the pain to decrease from [8-27] to [2-27]. She described the pain as pressure ??????like someone punched me in the chest?????? substernally. She had pseudonormalization of ekg from admission. CE's flat x3. She was transferred from the ICU to cardiology service for further workup, which included a cardiac catheterization that showed findings c/w prior cath, including patent stent in Lcx, 60% lesion OM1, 50% midsegment lesion in LAD and 50% mid segment lesion in RCA. No interventions were done. She was discharged on aspirin 325, home dose of simvastatin 40 mg daily, and metoprolol at decrased dose from home of 100 mg daily (presented with lower blood pressures). # Lactic acidosis: Likely due to severe dehydration over a protracted course of hyperglycemia or infectious etiology. Improved during admission. # Diarrhea: Resolved in ICU. History of frequent diarrhea. Possible source is gastroenteritis, no diarrhea noted on cardiology service. # Hypertension: HTN on history. Low normotensive here, so antihypertensives initally held. Was restarted on lisinopril and metoprolol at lower dose, home diltiazem and hydrochlorothiazide held on discharge. # GERD: continued omeprazole. . # Code: DNR/DNI (discussed with patient) Medications on Admission: glargine 40 units at night diltiazem HCl [Cartia XT] 240 mg PO daily glipizide 10 mg PO BID hydrochlorothiazide 25 mg PO daily hydrocortisone [Proctosol HC] 2.5 % Cream PR [Hospital1 ], prn hemorrhoids insulin glargine [Lantus] 40 units SQ daily lisinopril 20 mg Tablet PO daily meclizine 12.5 mg PO TID prn dizziness metformin 1,000 mg PO BID metoprolol tartrate 200 mg PO daily nitroglycerin 0.3 mg SL prn chest pain omeprazole 20 mg PO daily simvastatin 40 mg PO HS ascorbic acid Dosage uncertain aspirin 500 mg PO daily B complex vitamins Dosage uncertain One Touch Ultra Test Strip calcium dosage uncertain ferrous sulfate 325 (65) mg PO BID lancets [One Touch UltraSoft Lancets] magnesium Dosage uncertain multivitamin-minerals-lutein [Centrum Silver] naproxen sodium [Aleve] 220 mg PO BID potassium Dosage uncertain ranitidine HCl [Zantac] Dosage uncertain vit C-vit E-copper-ZnOx-lutein [PreserVision] Dosage uncertain vitamin E Dosage uncertain Discharge Medications: 1. insulin glargine 100 unit/mL Cartridge Sig: Forty (40) units Subcutaneous once a day. 2. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for dizziness. 7. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day. 8. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 9. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 10. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual PRN as needed for chest pain. 11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 12. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day: as directed by sliding scale. 13. Proctosol HC 2.5 % Cream Sig: One (1) Rectal twice a day as needed for hemorrhoids. 14. B Complex Capsule Sig: One (1) Capsule PO once a day. 15. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1) Tablet PO once a day. 16. multivitamin Tablet Sig: One (1) Tablet PO once a day. 17. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day. 18. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 19. vitamin E 400 unit Tablet Sig: One (1) Tablet PO once a day. 20. clotrimazole 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 533] [Last Name (NamePattern1) ] for Extended Care - [Location 1268] Discharge Diagnosis: Diabetes mellitus Diabetic ketoacidosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were seen in the hospital for elevated blood sugars. For this you were in the intensive care unit and had to receive insulin by IV. It is very important that you take insulin as directed in order to get better control of your blood sugar and avoid complications of diabetes, including worsening heart disease, eye problems, and nerve damage. You were also transferred to the cardiology service for chest pain. A cardiac catheterization was performed which showed no new blockages in the blood vessels supplying your heart which needs intervention or a procedure at this time. Changes to your medications: DECREASE metoprolol to 100 mg a day STOP taking hydrochlorothiazide STOP taking diltiazem Followup Instructions: Please follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Location (un) 2274] Cardiology. We will schedule an appointment for you. If you don't hear from the clinic in 1 week please call [Telephone/Fax (1) ]. Department: [Hospital3 249] When: WEDNESDAY [2110-4-23] at 9:40 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ],ANP-BC [Telephone/Fax (1) 250] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2110-4-15] Name: [Known lastname 4971],[Known firstname 2219] Unit No: [Numeric Identifier 15537] Admission Date: [2110-4-10] Discharge Date: [2110-4-15] Date of Birth: [2039-7-14] Sex: F Service: MEDICINE Allergies: Codeine / Milk Attending:[First Name3 (LF) 13884] Addendum: In discharge instructions, patient noted to be discharged to Home with Services. This is incorrect, patient was discharged to Extended Care Facility (The [First Name4 (NamePattern1) 204] [Last Name (NamePattern1) ]). Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 204] [Last Name (NamePattern1) ] for Extended Care - [Location 205] [First Name11 (Name Pattern1) 6393] [Last Name (NamePattern4) 13885] MD [MD Number(2) 13886] Completed by:[2110-4-16]	[ "733.00", "414.01", "401.9", "250.12", "787.91", "786.59", "V45.82", "530.81", "V49.86", "V15.81" ]	icd9cm	[ [ [] ] ]	[ "88.56" ]	icd9pcs	[ [ [] ] ]	13875, 14172	6609, 8900	295, 321	11809, 11809	4127, 4127	12689, 13852	2659, 2939		9912, 11567		11746, 11788		8926, 9889			11960, 12545								2261, 2439	2979, 3573																		12574, 12666						237, 257										349, 2045							4144, 6586				11824, 11936				2067, 2237	2455, 2643				3598, 4108
23,845	172,899	45729	Discharge summary	report	Admission Date: [2110-6-9] Discharge Date: [2110-6-10] Date of Birth: [2044-3-11] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor First Name 1402] Chief Complaint: abnormal heart rhythm Major Surgical or Invasive Procedure: none History of Present Illness: 66M transferred to CCU for atrial fibrillation with rapid ventricular response and 10s sinus pauses and blackouts. Pt with history of CAD-s/p CABG in [2100]--post-op afib at that time, then OK for years--[9-9]-eD visit for rapid afib-spont converted, says well controlled recently, some palpitations over last [1-9] months, then this AM awoke with rapid irreg heart beat. No other symptoms, incl cp, chf symptoms, sob, n/v etc. No fevers --some chills recently--maybe feels like getting a cold. In the field, patient received 5mg IV metoprolol with no significant improvement in rate, but SBP120s. In ED, patient received two additional doses of IV metoprolol 5mg push with no further improvement. Patient received 5mg diltiazem IV push and began to experience 10s pauses w/ single sinus beat - appearing as though patient spontaneously converting in the setting blocked AV node. Pt transferred to CCU initially w/ plans to cardiovert, however, given pauses in setting of sinus beats, decision made to defer at least until IV nodal agents cleared. Also, patient seen by GI and felt stable for anti-coagulation. Past Medical History: Ulcerative Colitis [2106], s/p polypectomy w/ high grade dysplasia - diarrhea stabilized on sulfasalazine s/p CABG [2100] Inguinal hernia Lipids HTN GERD Medications: Atenolol 50 Diovan 80 Folate Prilosec 20 Zocor 40 Flomax 0.4 Sulfasalazine 1g QID ASA 162 MVI Coenzyme Q Social History: The patient lives with his sister in [Name (NI) 1268]. He has about one to two alcoholic drinks per week. He quit cigarettes about thirty years ago. The patient is employed as an electrical engineer. Family History: The patient's father as well as two of his uncles had coronary artery disease. His maternal aunt had [Name2 (NI) 499] cancer. Physical Exam: VS 94.2kg 128 132/77 27 97% 2L GENERAL: NAD HEENT: PERRL, EOMI, OMMM NECK: JVP 8cm, Supple, no LAD CARDIOVASCULAR: S1, S2, no MRG LUNGS: CTAB ABDOMEN: soft, NT, ND, no rebound or guarding. EXTREMITIES: no LE edema, no clubbing. NEURO: A/O X 3, Strength and Sensation grossly intact Pertinent Results: [2110-6-9] 11:48PM URINE COLOR-Amber APPEAR-Clear SP [Last Name (un) 155]-1.025 [2110-6-9] 11:48PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2110-6-9] 08:56PM PTT-53.2* [2110-6-9] 12:55PM GLUCOSE-112* UREA N-16 CREAT-1.1 SODIUM-141 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-27 ANION GAP-15 [2110-6-9] 12:55PM CK(CPK)-102 [2110-6-9] 12:55PM CK-MB-2 cTropnT-<0.01 [2110-6-9] 12:55PM CALCIUM-9.6 PHOSPHATE-3.2 MAGNESIUM-2.0 [2110-6-9] 12:55PM TSH-3.4 [2110-6-9] 12:55PM WBC-11.1# RBC-5.23 HGB-15.1 HCT-46.5 MCV-89 MCH-28.9 MCHC-32.5 RDW-15.2 [2110-6-9] 12:55PM NEUTS-74.8 LYMPHS-18.3 MONOS-6.1 EOS-0.6 BASOS-0.2 [2110-6-9] 12:55PM PLT COUNT-138* [2110-6-9] 12:55PM PT-12.3 PTT-23.6 INR(PT)-1.0 CHEST PA AND LATERAL: The patient is status post CABG. The heart size is in the upper limits of normal . The lungs are clear. There are no pleural effusions. The pulmonary vasculature is normal. Degenerative changes are seen in the mid thoracic spine. IMPRESSION: No acute cardiopulmonary process. Brief Hospital Course: 66M s/p CABG [2100] w/ post-op afib, UC, returns w/ Afib/RVR and 10s pauses, converted to NSR without pauses (off all nodal blocking agents). Patient was admitted to CCU with plans for DC cardioversion and was started on heparin gtt for anticoagulation. DC cardioversion was deferred given continued pauses. However, [2-7] hours following admission, patient converted spontaneously to normal sinus rhythm without complications. Anticoagulation was discontinued on hospital day two. Hematocrit fell by ~7points (46.5->38.9) from presentation to following admission, however was stable on day two. Patient was counseled to followup with primary care physician to have hematocrit redrawn two days following discharge. Patient was stable in normal sinus rhythm at the time of discharge. Medications on Admission: Atenolol 50 Diovan 80 Folate Prilosec 20 Zocor 40 Flomax 0.4 Sulfasalazine 1g QID ASA 162 MVI Coenzyme Q Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Simvastatin 40 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. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Atrial Fibrillation with rapid ventricular response Discharge Condition: Good in normal sinus rhythm, hemodynamically stable. Discharge Instructions: Continue taking your medications as directed. Stop taking atenolol and start taking metoprolol as directed. Return to see your primary care physician within the next two days to have your hematocrit checked. Return to see your gastroenterologist in followup as planned. Followup Instructions: Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 6925] Where: [Hospital6 29] MEDICAL SPECIALTIES Phone:[Telephone/Fax (1) 1954] Date/Time:[2110-8-5] 1:30 Provider: [Name Initial (NameIs) ] SUITE GI ROOMS Where: GI ROOMS Date/Time:[2110-9-8] 7:30 Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 6925],MD Where: [First Name8 (NamePattern2) ] [Hospital Ward Name ] BUILDING([Hospital Ward Name ]/[Hospital Ward Name ] COMPLEX) ENDOSCOPY SUITE Phone:[Telephone/Fax (1) 463] Date/Time:[2110-9-8] 7:30	[ "556.9", "427.31", "530.81", "272.0", "V17.3", "426.10", "401.9", "V15.82", "593.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	5236, 5242	3639, 4438	337, 343	5338, 5392	2488, 3616	5713, 6309	2039, 2170		4594, 5213		5263, 5317		4464, 4571			5416, 5690									2185, 2469																								276, 299										371, 1497															1519, 1802	1818, 2023
67,620	100,277	41750	Discharge summary	report	Admission Date: [2162-7-28] Discharge Date: [2162-7-31] Date of Birth: [2080-3-22] Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3190] Chief Complaint: ?Guillain-[Location (un) ] Major Surgical or Invasive Procedure: Bronchoscopy and bronchial lavage: 8/3 [2162-7-29] 1. Total laminectomy of C3, 4, 5, 6 and 7. 2. Fusion C3 to 7. 3. Autograft and allograft. History of Present Illness: 82 y/o male with PMHx breast CA s/p mastectomy in [5-/2162] c/b right frozen shoulder, squamous cell CA of the penis s/p resection, glaucoma who is being transferred for concern of Guillain-[Location (un) ] syndrome. Per the pt's niece, he was in his usual state of health until [7-24], when he fell while unloading a piece of furniture from his car. Per OSH notes, he did not lose conciousness nor complain of any cardiac prodrome - he felt this was a mechanical fall. He was too weak to get up on his own and was on the ground for ~2 hours prior to being found by his neighbor. [Name (NI) ] was taken to [Hospital3 ] and admitted to a telemetry unit. He was noted to have elevated CK, which peaked at 3320, then trended down with IVF. Cardiology was consulted but felt this was a mechanical fall and had planned to obtain an echocardiogram. On [7-25], the patient was noted to have increased weakness and progressed to a feeling of an inability to move his extremities on [7-26]. Shortly after this, he became bradycardic and hypotensive and went into respiratory failure. He was intubated, had CPR performed, then was transferred to the CCU. He was intermittently on pressors and was felt to have developed an aspiration pneumonia. He was initially on clindamycin, then broadened to vancomycin and cefepime. His O2 requirement improved and there were plans to extubate him on [7-28], however a NIF was noted to be -10 and the patient was noted to have complete paralysis of bilateral extremities. CT was negative, neuro consulted and felt he may have an ascending paralysis such as GBS and recommended transfer to a tertiary care facility. . In the ICU, the patient is intubated. He is able to shake his head yes and no to questions. Past Medical History: Breast CA s/p mastectomy [5-/2162] penile Squamous cell CA s/p resection Glaucoma Social History: - Tobacco: none - Alcohol: none - Illicits: none Family History: Unknown Physical Exam: Vitals: T: BP: P: RR: SpO2: General: Intubated HEENT: Sclera anicteric, MMM, oropharynx clear Lungs: Decreased breath sounds on the left, coarse breath sounds on right CV: RRR, normal S1 + S2, tachycardic Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: able to shake head yes and no to simple questions, Pupils track across midline. Right hand with minimal movement when asked to squeeze, no movement in rest of extremities - sensation unable to be assessed - no reflexes noted on exam Rectal exam deferred until collar able to be placed Pertinent Results: Admission Labs: [2162-7-28] 07:40PM WBC-7.1 RBC-4.07* HGB-12.9* HCT-35.6* MCV-87 MCH-31.7 MCHC-36.3* RDW-13.0 [2162-7-28] 07:40PM NEUTS-83* BANDS-3 LYMPHS-5* MONOS-8 EOS-0 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [2162-7-28] 07:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2162-7-28] 07:40PM PT-13.3 PTT-30.0 INR(PT)-1.1 [2162-7-28] 07:40PM GLUCOSE-147* UREA N-16 CREAT-0.6 SODIUM-139 POTASSIUM-3.5 CHLORIDE-106 TOTAL CO2-27 ANION GAP-10 [2162-7-28] 07:40PM ALT(SGPT)-67* AST(SGOT)-52* LD(LDH)-219 CK(CPK)-629* ALK PHOS-43 TOT BILI-0.8 [2162-7-28] 07:40PM CK-MB-4 cTropnT-<0.01 [2162-7-28] 07:40PM ALBUMIN-3.2* CALCIUM-7.6* PHOSPHATE-2.7 MAGNESIUM-2.2 [2162-7-28] 08:00PM TYPE-ART TEMP-37.2 RATES-14/6 TIDAL VOL-500 PEEP-5 O2-100 PO2-65* PCO2-40 PH-7.45 TOTAL CO2-29 BASE XS-3 AADO2-617 REQ O2-99 INTUBATED-INTUBATED . Microbiology: Bronchial lavage ([7-28]): [2162-7-28] 10:37PM OTHER BODY FLUID POLYS-86* LYMPHS-1* MONOS-13* . Imaging: CXR ([7-28]): MR [Name13 (STitle) ] ([8-24]: FINDINGS: There is exaggerated lordosis of the cervical spine. There is minimal retrolisthesis of C4 over C5 vertebra by 4 mm. The vertebral bodies are normal in height and marrow signal intensity. There is no evidence of acute fracture. Prevertebral soft tissue is noted from C1 to C5 level. Hyperintensity is noted in posterior paraspinal muscles and soft tissues from C1 to C6 levels. A small hypointense area is noted in right paraspinal muscles at the C7-T1 level measuring 1.8 x 1.4 x 1.7 cm in craniocaudad, AP, and transverse dimensions. This likely represents calcification. There is multilevel disc degenerative disease. There is desiccation of all cervical intervertebral discs. At C2-C3 level, there is no significant spinal canal or neural foraminal narrowing. At C3-C4 level, there is a broad-based posterior disc protrusion causing indentation and compression of spinal cord. There is severe spinal canal stenosis. The disc with uncovertebral and facet osteophytes causes moderate bilateral foraminal stenosis. At C4-C5, there is posterior disc protrusion causing indentation and compression of the spinal cord and severe spinal canal narrowing. The disc with uncovertebral and facet osteophytes causes moderate right and mild left foraminal narrowing. At C5-C6, there is diffuse posterior disc bulge causing indentation of the anterior subarachnoid space. There is no evidence of significant spinal canal or neural foraminal narrowing. At C6-C7 level, there is diffuse posterior disc bulge without significant spinal canal or neural foraminal narrowing. Hyperintense signal is noted in cervical spinal cord from C2 to C7 level. This likely represents combination of compressive edema and contusion secondary to fall. Brief Hospital Course: 82 y/o male with PMHx breast CA s/p mastectomy in [5-/2162] c/b right frozen shoulder, squamous cell CA of the penis s/p resection, glaucoma with neurologic signs concerning for cervical spine injury vs GBS vs myositis. . # Weakness/paralysis - Concerning for cervical spine injury (may have occurred during intubation) vs ascending paralysis such as GBS vs myositis/myopathy given elevated CK on admission. Patient has no clear history of prodromal illness for GBS, but this is not necessary for the diagnosis. CK trending down without any intervention for myositis making it less likely. MR [Name13 (STitle) 2853] performed early [7-29] showed chronic DJD of C-spine with significant narrowing of spinal canal, compression of spinal cord, and associated edema from C3-T1. Spine surgery was consulted and felt that the paralaysis is secondary to spinal cord compression with poor prognosis if patient taken to the OR and very low probability of recovery of any function. Spine surgery had a discussion with family who chose to pursue surgical repair. . # Hypoxemic respiratory failure - [1-27] diaphragmatic weakness and pneumonia/mucus plugging. CXR on presentation showed complete whiteout of left lung - bronchoscopy the evening of [7-28] showed copious amounts of mucus plugging that was suctioned out. Post bronch, has been able to be weaned to 60% FiO2. A repeat CXR on [7-29] showed substantial improvement, with possible consolidation in the LLL. Due to neuromuscular dysfunction, he was continued on ventilation. . # HCAP - Signs of LLL PNA seen on bronchoscopy with edematous, red airways. Was thought to have aspirated at OSH and covered with vanco/cefepime. Has been in hospital > 48 hours so needs to be covered for HCAP. Plan to continue coverage and request sputum culture results from OSH. . # Thrombocytopenia - Platelets of 114 on [7-28], down from 147 on admission to OSH. No signs of spontaneous bleeding at this time. Differential includes med effect vs decreased production. . # Anemia - Mild normocytic anemia. On admission Hgb was 14.7. [Month (only) 116] be [1-27] dilution vs decreased production vs bleed (although no evidence). Plan to follow CBC. . # Elevated AST/ALT - mildly elevated, other LFTs are normal including bili. [Month (only) 116] be related to periods of hypotension. Plan to trend LFTs. . # Bradycardia - Bradycardic at OSH, has been stable here. [Month (only) 116] be secondary to [Last Name (un) 4584]-[Location (un) ] or other neuro problem affecting autonomic nervous system. Presumably, was ruled out for MI after this happened but unknown if this did happen. EKG shows no evidence of infarct. Echo planned for [7-29], may be deferred given emergent surgical intervention. . # Elevated CK - Likely secondary to rhabdo from fall, CK's have been trending down without acute intervention and renal function is stable. . # FEN: IVF as needed, replete electrolytes, NPO for now # Prophylaxis: Pneumoboots and subQ heparin # Access: peripherals # Communication: Patient # Disposition: Patient was transferred to [Hospital Ward Name ] trauma ICU for possible surgical intervention per Spine surgery In the evening of [2162-7-30], after discussion with patient and family members, the patient's code status was changed to Comfort Measures Only. His pain was controlled with IV morphine. At 1030pm, the patient was noted to have no respiratory drive, no pulse and no heart/lung sounds. The on call resident was called to evaluate the patient, and the patient was pronounced dead at 1040pm on [2162-7-30]. Medications on Admission: Home Medications: Xalatan Combivent MVI Advil Discharge Disposition: Expired Discharge Diagnosis: Cervical stenosis/spondylosis Quadraplegia Pneumonia Discharge Condition: Expired Completed by:[2162-8-16]	[ "285.9", "934.9", "V10.49", "518.81", "344.00", "733.00", "721.1", "336.9", "V10.3", "287.5", "486", "E915" ]	icd9cm	[ [ [] ] ]	[ "96.71", "77.79", "81.63", "96.05", "81.03" ]	icd9pcs	[ [ [] ] ]	9854, 9863	6118, 9757	340, 487	9959, 9997	3240, 3240		2495, 2504				9884, 9938		9783, 9783												2519, 3221					9801, 9831																			269, 302										515, 2299							3256, 6095								2321, 2409	2425, 2479
67,853	178,133	16932+56812	Discharge summary	report+addendum	Admission Date: [2110-12-25] Discharge Date: [2110-12-30] Date of Birth: [2045-7-16] Sex: F Service: ORTHOPAEDICS Allergies: Codeine / Hydromorphone Attending:[First Name3 (LF) 64] Chief Complaint: Left Hip Pain. Major Surgical or Invasive Procedure: Complex conversion of failed left dynamic hip compression screw to a cemented left hip hemiarthroplasty with strut allograft, cerclage, trephine, removal of failed deep hardware. History of Present Illness: HPI: 65 yo F who underwent left TKA with Dr. [Last Name (STitle) ] [9-/2109] and then suffered a left hip fx in 5/[2109]. She then underwent ORIF with a dynamic compression hip screw at an outside hospital. Unfortunately the implant failed and the patient suffered from a nonunion, subsequent collapse, and repeat fracture of the hip. She presented for removal of hardware and left hip arthroplasty. Past Medical History: PMH: NIDDM, HL, GERD, Liver disease (cryptogenic cirrhosis with portal hypertension), Daily narcotic use, OA, Bipolar disease, Esophageal varices, Essential tremor, Anemia PSH: Left TKA, partial hysterectomy, appendectomy, Left hip DHS Social History: SH: Former smoker, no EtOH. Married with very supportive husband. Family History: Noncontributory. Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Left Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * 5/5 strength TA/GS/[Last Name (un) 938]/FHL * SILT DP/SP/T/S/S * Toes warm Pertinent Results: [2110-12-25] 06:55PM BLOOD WBC-8.6# RBC-3.01* Hgb-8.8* Hct-26.4* MCV-88 MCH-29.1 MCHC-33.3 RDW-14.5 Plt Ct-189# [2110-12-25] 10:20PM BLOOD WBC-12.6* RBC-3.47* Hgb-10.4* Hct-29.9* MCV-86 MCH-29.9 MCHC-34.6 RDW-14.3 Plt Ct-158 [2110-12-25] 06:55PM BLOOD PT-15.0* PTT-29.7 INR(PT)-1.3* [2110-12-25] 10:20PM BLOOD PT-14.7* PTT-26.5 INR(PT)-1.3* [2110-12-25] 10:20PM BLOOD Glucose-228* UreaN-13 Creat-0.5 Na-138 K-4.5 Cl-108 HCO3-24 AnGap-11 [2110-12-26] 08:04AM BLOOD WBC-10.9 RBC-3.18* Hgb-9.3* Hct-27.3* MCV-86 MCH-29.2 MCHC-34.0 RDW-14.7 Plt Ct-153 [2110-12-26] 04:39PM BLOOD Hct-23.1* [2110-12-26] 04:53AM BLOOD PT-15.3* PTT-26.9 INR(PT)-1.3* [2110-12-26] 04:53AM BLOOD Glucose-164* UreaN-13 Creat-0.6 Na-138 K-4.4 Cl-110* HCO3-22 AnGap-10 Calcium-8.6 Phos-3.0# Mg-1.2* [2110-12-27] 05:31AM BLOOD WBC-7.6 RBC-3.02* Hgb-8.9* Hct-26.7* MCV-88 MCH-29.3 MCHC-33.1 RDW-14.7 Plt Ct-88* [2110-12-27] 12:50PM BLOOD WBC-7.1 RBC-2.76* Hgb-8.1* Hct-23.9* MCV-87 MCH-29.5 MCHC-34.1 RDW-15.0 Plt Ct-99* [2110-12-27] 07:10PM BLOOD Hct-26.7* [2110-12-27] 05:31AM BLOOD PT-14.6* PTT-26.9 INR(PT)-1.3* [2110-12-27] 05:31AM BLOOD Glucose-177* UreaN-13 Creat-0.6 Na-133 K-3.6 Cl-105 HCO3-21* AnGap-11 Calcium-8.4 Phos-2.6* Mg-1.9 [2110-12-28] 02:20AM BLOOD Hct-28.1* [2110-12-28] 05:00AM BLOOD WBC-7.3 RBC-3.18* Hgb-9.4* Hct-27.9* MCV-88 MCH-29.6 MCHC-33.7 RDW-14.9 Plt Ct-109* [2110-12-28] 10:30AM BLOOD Hct-26.5* [2110-12-28] 03:00PM BLOOD PT-14.3* INR(PT)-1.2* [2110-12-28] 05:00AM BLOOD Glucose-166* UreaN-20 Creat-0.8 Na-133 K-3.6 Cl-101 HCO3-23 AnGap-13 Calcium-8.6 Phos-2.6* Mg-1.8 [2110-12-29] 05:20AM BLOOD WBC-6.4 RBC-2.79* Hgb-8.4* Hct-24.3* MCV-87 MCH-29.9 MCHC-34.4 RDW-15.3 Plt Ct-124* [2110-12-29] 05:20AM BLOOD PT-16.1* INR(PT)-1.4* [2110-12-29] 05:20AM BLOOD Glucose-128* UreaN-21* Creat-0.8 Na-132* K-3.4 Cl-100 HCO3-25 AnGap-10 Albumin-2.5* Calcium-8.8 Phos-2.0* Mg-1.6 [2110-12-30] 08:40AM BLOOD WBC-5.0 RBC-3.17* Hgb-9.7* Hct-26.9* MCV-85 MCH-30.5 MCHC-36.0* RDW-15.6* Plt Ct-139* [2110-12-30] 08:40AM BLOOD PT-27.1* PTT-35.7* INR(PT)-2.6* [2110-12-30] 08:40AM BLOOD Glucose-127* UreaN-13 Creat-0.5 Na-136 K-2.6* Cl-99 HCO3-29 AnGap-11 Albumin-2.8* Calcium-8.8 Phos-1.5* Mg-1.6 Brief Hospital Course: The patient was taken to the operating room on [2110-12-25] by Dr. [Last Name (STitle) ] for a complex hip procedure involving hardware removal and cemented hemiarthroplasty. The procedure consisted of complex conversion of failed left dynamic hip compression screw to a cemented left hip hemiarthroplasty with strut allograft, cerclage, trephine, removal of failed deep hardware. The EBL was 2000cc and UOP was 300cc. Products infused included Cellsaver 300cc, IVF 2000cc, 4u PRBC, and 3u FFP. Please see operative report for details. The patient tolerated the procedure well but was transferred intubated to the ICU secondary to blood loss and concern for coagulopathy. After testing she was found not to have a coagulopathy and her blood volume began to normalize, but she required several transfusions to accomplish this. She was extubated on POD#1 and transferred out of the ICU on POD#2. A Medicine Consult was requested and their recommendations were followed. Peri-operative antibiotics (both ancef and vancomycin) were given due to her history of staph aureus colonization (no MRSA documented). Lovenox for DVT prophylaxis was used as a bridge to coumadin anticoagulation. Coumadin was started on POD#3 in anticipation of at least 6 weeks of anticoagulation. Pain was controlled initially with a PCA and then transitioned to oral pain meds on POD#2. The foley was removed on POD#4 and the patient was voiding independently thereafter. The surgical dressing was changed on POD#2 and an incisional vac was placed. The vac was removed on POD#4 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. Postoperatively the patient was given a total of 6 units PRBC with the goal of keeping her Hct >26. While in the hospital, 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 diabetic diet and feeling well. She was afebrile with stable vital signs. On the day of discharge the patient's hematocrit was stable and her pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient progressed well with physical therapy. Post-operative Xrays demonstrated hardware in good position. The patient was discharged to rehab in stable condition. Daily Report: [12-25] (POD#0): Patient transferred to ICU intubated [1-20] concern for blood loss and possible coagulopathy. POC done by moonlighter. Left hip and femur Xrays [12-25]: hardware in good position, no evidence of complication. Hct 26.4, INR 1.3, Fibrinogen 299. [12-26] (POD#1): Extubated. Drain removed. Hct 23.1 so stayed in ICU. Transfused 2 units PRBC. Mg 1.2 repleted. INR 1.3. [12-27] (POD#2): Hct 26.7. Dressing changed and incisional vac placed to 75mm Hg continuous suction. Repeat Hct 23.9, ordered additional 2units PRBC. [12-28] (POD#3): Hct 27.9 and INR 1.2. [12-29]: Hct 23.4. Asymptomatic. Transfused an additional 2 units PRBC and gave 10mg IV lasix in between units. INR 1.4, ordered 2mg coumadin. Repleted lytes. Left hip and femur Xrays [12-29]: hardware in good position, no evidence of complication. [12-30]: Hct 26.9 and INR 2.6. Lovenox bridge discontinued. Labs notable for low potassium and phosphate: daily supplements started per Medicine Consult recommendations. Discharge to rehab. Medications on Admission: MEDS: Effexor, Zyprexa, Lamictal, Actonel, Ursodiol, Primidone, Simvastatin, Metformin, Potassium, Lasix, HCTZ, Lactulose, Dilaudid, Extra-strength Tylenol, Protonix, Colace, Iron, MVI ALL: Dilaudid IV, Codeine Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain: Do not drive, operate machinery, or drink alcohol while taking this medication. As your pain decreases, take fewer tablets and increase the time between doses. Take a stool softener to prevent constipation. 2. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO Q6H (every 6 hours) as needed for Dyspepsia. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Hold for loose stools. 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO BID (2 times a day) as needed for Constipation. 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Primidone 250 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 15. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for Constipation. 16. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily): 25mg PO daily. 17. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO DAILY (Daily): 150mg PO daily. 18. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 19. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Insulin Lispro 100 unit/mL Solution Sig: 1 - 3 units Subcutaneous ASDIR (AS DIRECTED): for blood glucose control. 21. Olanzapine 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime): 10mg PO QHS. 22. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours): do not exceed 4000mg Tylenol per 24hr period. 23. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for SBP<100. 24. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): 400mg PO TID. 25. Warfarin 2 mg Tablet Sig: Variable Tablet PO Once Daily at 4 PM: Goal INR 2.0 - 2.5, Last dose 2mg on [2110-12-29]. 26. Dextrose 50% in Water (D50W) Syringe Sig: One (1) Syringe Intravenous PRN (as needed) as needed for hypoglycemia protocol. 27. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): 10mg [Hospital1 ]. Please give [Hospital1 ] potassium supplement at the same time. . 28. Potassium & Sodium Phosphates 280-160-250 mg Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily). 29. Potassium Chloride 20 mEq Packet Sig: Two (2) 20mEq packets PO BID (2 times a day): 40mg [Hospital1 ]. Please give [Hospital1 ] lasix at the same time. . Discharge Disposition: Extended Care Facility: Life Care Center of [Location (un) 5165] Discharge Diagnosis: Failed left dynamic hip compression screw with four part intertrochanteric femur fracture and avascular necrosis of the femoral head. Discharge Condition: AVSS, hemodynamically stable, pain well-controlled, tolerating a regular diet, voiding independently, ambulating with crutches, neurovascularly intact distally. Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - requires assistance or aid (walker or cane) 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. While you were in the hospital you were found to have consistently low potassium and phosphate levels. this is dangerous in patients with liver disease because it can cause encephalopathy. We have started potassium and phosphate supplements. Your electrolytes should be checked every other day and the doses of potassium and phosphate supplements revised accordingly. Goal potassium is [3-23] and goal phosphate is > 2.5. In addition, your creatinine should be monitored while taking lasix. 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. You may not drive a car until cleared to do so by your surgeon or your primary physician. 6. 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 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 Coumadin with a goal INR of 2.0 - 2.5. Coumadin therapy will continue for at least 6 weeks: total duration of therapy to be determined at your follow-up appointment with Dr. [Last Name (STitle) ]. INR should be checked daily at rehab and Coumadin dosed accordingly. Due to your liver disease, INR may be hypersensitive to Coumadin dosage adjustments and should be checked daily. When you leave rehab your INR and Coumadin dosing will be followed by your PCP or by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in Dr. [Last Name (STitle) 67] office. INR can then be checked every other day by the VNA. Please call [Telephone/Fax (1) 1228] if there is any confusion about who will follow your INR and adjust your Coumadin doses. 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. INR checks and Coumadin dosing as above. Monitoring of electrolytes (particularly potassium and phosphate) as above. 12. ACTIVITY: Weight bearing as tolerated on the operative extremity. Posterior hip precautions and trochanteric osteotomy precautions. No active abduction and no excessive hip flexion, adduction, or internal rotation. Abduction pillow while in bed. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: ACTIVITY: Weight bearing as tolerated on the operative extremity. Posterior hip precautions and trochanteric osteotomy precautions. No active abduction and no excessive hip flexion, adduction, or internal rotation. Abduction pillow while in bed. No strenuous exercise or heavy lifting until follow up appointment. Treatments Frequency: 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. Followup Instructions: Provider: [First Name11 (Name Pattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3260], [MD Number(3) 3261]:[Telephone/Fax (1) 1228] Date/Time:[2111-1-23] 1:40 Completed by:[2110-12-30] Name: [Known lastname 8805],[Known firstname 46] Unit No: [Numeric Identifier 8806] Admission Date: [2110-12-25] Discharge Date: [2110-12-30] Date of Birth: [2045-7-16] Sex: F Service: ORTHOPAEDICS Allergies: Codeine / Hydromorphone Attending:[First Name3 (LF) 370] Addendum: Patient discharged to Lifecare Center of [Location (un) 8807] [2110-12-30]. Discharge instructions amended to include follow-up information for INR monitoring and Coumadin dosing by patient's PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 6206]. [First Name8 (NamePattern2) 8808] [Last Name (NamePattern1) 8809] pager [Numeric Identifier 8810] Discharge Disposition: Extended Care Facility: Life Care Center of [Location (un) 8807] Discharge Diagnosis: Failed left dynamic hip compression screw with four part intertrochanteric femur fracture and avascular necrosis of the femoral head. Discharge Condition: AVSS, hemodynamically stable, pain well-controlled, tolerating a regular diet, voiding independently, ambulating with crutches, neurovascularly intact distally. Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - requires assistance or aid (walker or cane) 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. While you were in the hospital you were found to have consistently low potassium and phosphate levels. This is dangerous in patients with liver disease because it can cause encephalopathy. We have started potassium and phosphate supplements. Your electrolytes should be checked every other day and the doses of potassium and phosphate supplements revised accordingly. Goal potassium is [3-23] and goal phosphate is > 2.5. In addition, your creatinine should be monitored while taking lasix. 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. You may not drive a car until cleared to do so by your surgeon or your primary physician. 6. 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 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 Coumadin with a goal INR of 2.0 - 2.5. Coumadin therapy will continue for at least 6 weeks: total duration of therapy to be determined at your follow-up appointment with Dr. [Last Name (STitle) ]. Due to your liver disease, INR may be hypersensitive to Coumadin dosage adjustments. INR must be checked daily at rehab and Coumadin dosed accordingly. Your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 6206] will follow your INR and Coumadin dosing. Lab results (including PT and INR) must be faxed to Dr.[Name (NI) 8811] office at [Telephone/Fax (1) 8812] every day (Attn: Dr. [Last Name (STitle) 6206]. When you leave rehab your INR and Coumadin dosing will continue to be followed by Dr. [Last Name (STitle) 6206]. 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. INR checks and Coumadin dosing as above. Monitoring of electrolytes (particularly potassium and phosphate) as above. 12. ACTIVITY: Weight bearing as tolerated on the operative extremity. Posterior hip precautions and trochanteric osteotomy precautions. No active abduction and no excessive hip flexion, adduction, or internal rotation. Abduction pillow while in bed. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: ACTIVITY: Weight bearing as tolerated on the operative extremity. Posterior hip precautions and trochanteric osteotomy precautions. No active abduction and no excessive hip flexion, adduction, or internal rotation. Abduction pillow while in bed. No strenuous exercise or heavy lifting until follow up appointment. Treatments Frequency: 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. Followup Instructions: Provider: [First Name11 (Name Pattern1) 33] [Initial (NamePattern1) ] [Last Name (NamePattern4) 6108], [MD Number(3) 1117]:[Telephone/Fax (1) 809] Date/Time:[2111-1-23] 1:40 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 372] MD [MD Number(2) 373] Completed by:[2110-12-30]	[ "333.1", "285.1", "996.49", "998.11", "296.80", "E878.1", "998.13", "530.81", "733.42", "250.00", "572.3", "272.4", "571.5", "733.82" ]	icd9cm	[ [ [] ] ]	[ "81.52", "99.07", "78.65", "99.04" ]	icd9pcs	[ [ [] ] ]	17506, 17577	4179, 7642	303, 484	17755, 17917	1858, 4156	22844, 23200	1287, 1305		7904, 11145		17598, 17734		7668, 7881			18094, 20965									1320, 1839	22015, 22330	22352, 22352																						249, 265							22364, 22821			512, 926											17931, 18070				948, 1187	1203, 1271
15,930	184,061	20387+57151+57155	Discharge summary	report+addendum+addendum	Admission Date: [2146-4-9] Discharge Date: [2146-4-19] Date of Birth: [2075-6-22] Sex: F Service: CHIEF COMPLAINT: This is a 70-year-old female transferred from an outside hospital with hypoxemia, right pleural effusion, and mesenteric ischemia with mesenteric vein thrombosis/portal vein thrombosis. HISTORY OF THE PRESENT ILLNESS: The patient presented to the outside hospital on [2146-4-7] with complaints of abdominal pain, nausea, vomiting, diarrhea, and dyspnea for one to two days at the outside hospital. The white blood cell count was 24,000. The abdominal CT showed inflammation, edema of the entire small bowel and colon, and a thrombus in the mesenteric vein and portal vein. SA02 was 87% on room air which increased to 94% on 7 liters. ABG on 7 liters of oxygen showed a pH of 7.36, PC02 31, 02 of 73, anion gap 13. Chest x-ray showed a right pleural effusion. The effusion was tapped; 800 cc was removed and analyzed. It was consistent with a transudate. An echocardiogram was performed which showed an EF of 30% and global hypokinesis with 2+ MR. A Swan was performed which showed PA pressures of 30/10, pulmonary capillary wedge pressure of 10 with poor wave output. The blood pressure was 140s-150s/60s-80s which decreased to systolic of 110s/50s after the use of nitroglycerin past and Natrecor with Lasix. PAST MEDICAL HISTORY: 1. Diverticulitis, status post sigmoid resection in [2145-3-20] with a diverting colostomy which was reversed in [2145-11-20]. 2. Hypertension. 3. Hyperlipidemia. 4. Iron-deficiency anemia. 5. Glaucoma. 6. Allergic rhinitis. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON TRANSFER: 1. Levaquin. 2. Ceftriaxone. 3. Flagyl. 4. Protonix. 5. Nitroglycerin paste one-half inch every six hours. 6. Digoxin 0.25 mg IV. 7. Natrecor. 8. Heparin GGT. 9. Morphine. 10. Saline. MEDICATIONS AT HOME: 1. Xanax. 2. Prilosec. 3. Timolol. 4. Xalatan eyedrops. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 96.9, pulse 115, regular, blood pressure 112/66, respiratory rate 16, oxygen saturation 96% on 6 liters nasal cannula. General: The patient is anxious. HEENT: The pupils were equal, round, and reactive to light and accommodation. Extraocular movements were intact. Neck: JVP was flat. Lungs: Decreased air movement, poor effort. Cardiovascular: Tachycardiac but regular. No murmurs, rubs, or gallops. Abdomen: Distended, diffusely tender to percussion, no guarding. Extremities: There was +3 edema in the lower thigh. LABORATORY/RADIOLOGIC DATA: The laboratories from the outside hospital revealed a white count of 25, hematocrit 42, bicarbonate 21, creatinine 1.3, albumin 1.8. HOSPITAL COURSE: The patient was thought to have mesenteric ischemia secondary to mesenteric vein thrombosis. CTA of the abdomen was performed which showed a thrombus in the mesenteric vein and posterior portal vein. The patient was seen by Surgery and Vascular Surgery. The patient was started on anticoagulation with a heparin drip. Lactates were followed serially as well as serial abdominal examinations. The patient's abdominal examination improved during the hospital course. Lactate levels remained low, from 1.0 to 1.4. After nearly one week of hospitalization, a repeat abdominal ultrasound was performed to visualize flow. There was no evidence of portal or mesenteric vein thrombosis. The patient was kept n.p.o. during the hospitalization and given intravenous fluids. The patient was also given parental nutrition. The patient was also placed on broad spectrum antibiotics for prophylaxis of infection from enteric organisms. She was placed on ampicillin, levofloxacin, and Flagyl. The patient completed a 14 day course of these antibiotics. The patient had increased oxygen demand on admission. This was thought to be related to her CHF. Based on echocardiogram that was performed at [Hospital1 ], the patient had systolic dysfunction with an EF of 25-30%. The patient was aggressively diuresed; however, her respiratory status continued to decline. The patient became increasingly hypercarbic. The patient had increased work of breathing. Thoracentesis was performed with removal of nearly 1 liter. It was consistent with a transudate. The patient was intubated for increased work of breathing and hypercarbia/respiratory failure. The patient remained on the ventilator for three days. During that time, the patient was aggressively diuresed. Initially, she was placed on AC and gradually transitioned to pressure support and extubated on first attempt without difficulties. Soon after intubation, the patient exhibited bronchospasms with high airway resistance. She was started on IV steroids. The patient responded well with increased oxygenation, decreased hypercarbia, and wheezing. The patient was gradually weaned off the steroids during her hospital course in the Intensive Care Unit. CONDITION ON TRANSFER: Good, 98% on room air, no abdominal pain, tolerating a p.o. diet. [Name6 (MD) ] [Last Name (NamePattern4) ], M.D. Dictated By:[Name8 (MD) 10402] MEDQUIST36 D: [2146-4-19] 03:12 T: [2146-4-20] 18:05 JOB#: [Job Number 54664] Name: [Known lastname 10201], [Known firstname 471] Unit No: [Numeric Identifier 10202] Admission Date: [2146-4-9] Discharge Date: [2146-4-25] Date of Birth: [2075-6-22] Sex: F Service: Acove This is an addendum to the discharge summary dictated [2146-4-19]. SUMMARY OF HOSPITAL COURSE: (Addendum) 1. Portal mesenteric vein thrombosis - As mentioned in previous discharge summary, the patient was managed conservatively in the unit with intravenous antibiotics which were discontinued on the day of transfer to the floor, [2146-4-19], heparin drip with transition to Warfarin, serial abdominal examinations. At the time of discharge, the patient was therapeutic on Warfarin for over 48 hours and heparin had been discontinued. The cause of the patient's thrombosis is unclear. her initial abdominal computerized axial tomography scan was consistent with cirrhosis but this is not noted on the subsequent ultrasound dated [2146-4-14]. Her hepatitis panel was negative. She had a history of alcohol use, although the amount is unclear. A hypercoagulability workup was also initiated with Cardiolipin and Beta 2 glycoprotein antibodies which were negative. The remainder of the hypercoagulability workup will be pursued as an outpatient by the primary care physician. [Name10 (NameIs) ] patient will also require screening for metastatic disease as a possible cause for hypercoagulability including mammogram and colonoscopy as an outpatient. 2. Abdominal pain - The patient's abdominal pain was most likely secondary to post ischemic inflammation. The patient's liver function tests were not elevated suggesting that cholelithiasis or cholecystitis was unlikely. The patient's lactate had normalized by the time she was transferred to the General Medical Floor making continuing mesenteric ischemia less likely. At the time of discharge, the patient's abdominal pain had nearly completely resolved and she was tolerating a solid diet without difficulty. 3. Diarrhea - The patient's diarrhea noted in the unit and following transfer to the General Medical Floor is likely secondary to prior mesenteric ischemia. Clostridium difficile assays were negative times four and the patient's stool output has substantially decreased since admission. The patient will be continued on Loperamide as an outpatient. 4. Congestive heart failure - As mentioned previously, the patient's ejection fraction was noted to be 20 to 30% on echocardiogram. The patient was continued on Metoprolol, Lasix, and ACE inhibitor, (transitioned to Lisinopril), which were titrated up as tolerated. The patient's oxygen saturation improved following transfer to the floor and at the time of discharge she was sating 98% on room air. The patient currently has relatively even intake compared to urine output. Her lung examination and weight will need to be monitored on a regular basis as an outpatient to ensure that she is adequately diuresed to prevent congestive heart failure exacerbation. 5. Leukocytosis - The leukocytosis noted in the Intensive Care Unit was likely secondary to stress response, recent steroids, versus infection (urinary tract infection, pneumonia, and interim abdominal infection). The patient's chest x-ray was not suggestive of pneumonia and her urine culture and blood cultures were negative at the time of dictation. As mentioned above, the patient had four negative Clostridium difficile toxin assays. The patient's white blood cell count trended down and was within normal limits at the time of discharge. 6. Hypertension - The patient had alternating hyper and hypotension in the unit. However, given that her blood pressure was stable and in order to achieve maximal control of her congestive heart failure, the patient was started on Metoprolol and an ACE inhibitor as well as Lasix. The patient's blood pressure remained stable and these medications were titrated up prior to discharge. 7. Coronary artery disease - Although there is no documented history of coronary artery disease, the patient has a history of hypertension and hyperlipidemia with evidence of focal wall motion abnormalities on her echocardiograms. The patient had a cholesterol panel which did not suggest that she require a statin at this time, however, follow up panel when she has had a more sustained period of adequate p.o. intake will be required. Her outpatient primary care physician may consider [Name Initial (PRE) ] stress test for further workup of possible coronary artery disease. Given the patient's history of guaiac positive stool and the fact that she is currently anticoagulated, an aspirin was not given. This may be started as an outpatient at the discretion of her primary care physician. 8. Anemia - The patient's hematocrit was stable at the time of discharge. She has a history of iron deficiency anemia and is currently on iron. She will require period hematocrit check as an outpatient in order to ensure adequate iron replacements. As mentioned above, the patient will also require an outpatient colonoscopy and possibly an esophagogastroduodenoscopy. DISCHARGE STATUS: Discharge to extended care facility. DISCHARGE CONDITION: Fair. DISCHARGE INSTRUCTIONS: Please follow up with nausea, vomiting, abdominal pain, fevers, chills or increased diarrhea. FINAL DIAGNOSIS: Primary mesenteric and portal vein thrombosis. SECONDARY DIAGNOSIS: Hypertension, hyperlipidemia and anemia. RECOMMENDED FOLLOW UP: 1. Please follow up with primary care physician within one to two weeks following discharge. 2. Outpatient esophagogastroduodenoscopy and colonoscopy for evaluation of iron deficiency and guaiac positive stools. 3. Outpatient coronary artery disease evaluation for depressed left ventricular function and focal wall motion abnormalities. 4. Outpatient age-appropriate cancer screening and thrombophilia workup for spontaneous mesenteric thrombosis. DISCHARGE SERVICES: 1. The patient will require monitoring of her INR twice a week and adjustment of her Coumadin as necessary for an INR of 2 to 3. 2. The patient will require monitoring of her pulmonary status including oxygen saturation; and may need to adjust diuretics (Lasix) as needed. 3. The patient will require physical therapy three to five times a week to increase strength, endurance and mobility. MEDICATIONS ON DISCHARGE: 1. Timolol maleate 25% drops, 2 drops both eyes b.i.d. 2. Lantanaprost .005% one drop both eyes q.h.s. 3. Acetaminophen 325 to 650 mg p.o. q. 4-6 hours prn for fever or pain. 4. Zolpidem 5 mg p.o. q.h.s. prn insomnia. 5. Trazodone 25 mg p.o. q.h.s. prn insomnia. 6. Miconazole nitrate one application b.i.d. 7. Iron sulfate 325 mg p.o. q.d. 8. Ascorbic acid 500 mg p.o. b.i.d. 9. Albuterol metered dose inhaler 1 to 2 puffs q. 6 hours prn. 10. Atrovent 18 mcg aerosol metered dose inhaler 2 puffs q.i.d. 11. Lansoprazole 30 mg p.o. q.d. 12. Lisinopril 10 mg p.o. q.d. 13. Loperamide 2 mg p.o. q.i.d. prn diarrhea 14. Lasix 40 mg p.o. q.d. 15. Oxycodone 5 to 10 mg p.o. q. 4-6 hours prn. 16. Lorazepam .5 mg p.o. q. 4-6 hours prn anxiety. 17. Toprol XL 50 mg p.o. q.d. 18. Coumadin 2.5 mg p.o. q.h.s. 19. Promethazine 12.5 mg intravenously q. 6 hours prn nausea. [First Name4 (NamePattern1) 77] [Last Name (NamePattern1) ], M.D. [MD Number(1) 1977] Dictated By:[Last Name (NamePattern1) 834] MEDQUIST36 D: [2146-4-24] 14:37 T: [2146-4-24] 14:55 JOB#: [Job Number 10203] Name: [Known lastname 10201], [Known firstname 471] Unit No: [Numeric Identifier 10202] Admission Date: [2146-4-9] Discharge Date: [2146-4-25] Date of Birth: [2075-6-22] Sex: F Service: Acove ADDENDUM TO MEDICATIONS: The patient's INR was noted to be supertherapeutic the day of discharge. Her Coumadin dose was decreased to 2 mg q.h.s. Her INR should be rechecked three days post discharge and q. three days until her INR is in her goal range from 2 to 3. After that the patient will need her INR checked every two weeks to ensure that her Coumadin dose is in the therapeutic range. [First Name4 (NamePattern1) 77] [Last Name (NamePattern1) ], M.D. [MD Number(1) 1977] Dictated By:[Name8 (MD) 1314] MEDQUIST36 D: [2146-4-25] 12:17 T: [2146-4-25] 12:36 JOB#: [Job Number 10218]	[ "401.9", "452", "584.9", "276.3", "293.0", "428.0", "557.0", "518.81", "280.9" ]	icd9cm	[ [ [] ] ]	[ "96.71", "99.15", "93.90", "34.91", "96.04" ]	icd9pcs	[ [ [] ] ]				10560, 10567								11735, 13794		2761, 5624	10705, 10753	10592, 10687				1927, 2009													10840, 11709		5653, 10538														144, 1371														10775, 10829					2024, 2743					1712, 1906	1393, 1687
16,378	179,705	28970	Discharge summary	report	Admission Date: [2134-3-15] Discharge Date: [2134-3-22] Date of Birth: [2087-1-20] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 695] Chief Complaint: HBV cirrhosis and hepatocellular carcinoma Major Surgical or Invasive Procedure: Orthotopic liver transplant [2134-3-15] History of Present Illness: 47-year-old Chinese male with a history of hepatitis B recently diagnosed in [7-/2133] with corresponding liver cirrhosis. The patient has been maintained on Baraclude with an overall undetectable viral load. In the process of his workup, the patient underwent ultrasound in addition to a CT, which confirmed the presence of a liver mass within the right lobe measuring approximately 5 cm in greatest dimension. The patient underwent CT-guided biopsy in addition to radiofrequency ablation to the right hepatic lobe lesion on [2133-9-2]. At the time of diagnosis of hepatitis B and hepatoma, the patient's AFP was 788.8. After radiofrequency ablation, his AFP was reduced to 119 on [2133-9-21]. He had also been started on entecavir and has been successfully treated so that his HBV DNA is now undetectable. He completed a thorough pretransplant evaluation and was deemed an outstanding transplant candidate. He presented for this admission for liver transplant. Past Medical History: 1. Hepatitis B diagnosed in [7-/2133] in the setting of asymptomatic elevation in LFTs. Followup ultrasound and CT confirmed the diagnosis of hepatoma. The patient was started on Baraclude with an undetectable HBV viral load. The patient's AFP was 788.8. Status post radiofrequency ablation, it was 119. Core liver biopsy confirmed hepatocellular carcinoma, moderately differentiated. 2. History of chronic low back pain. 3. History of chronic dry cough. The patient reports a negative workup in the past and was told that this may be related to chronic acid reflux. Social History: The patient is married and has two children. The patient works fulltime at [Hospital ] Medical School within a cell biology lab. He is an immigrant of [Country 651]. He came to the United States in [2126]. He has been living in [Location (un) 86] since [35]/[2131]. The patient adamantly denies any hepatitis B exposures in the setting of IV drug abuse, tatoos, recent unprotected sexual intercourse, or prior blood transfusions. The patient reports his family has been tested and they remain negative. He reports a heavy history of alcohol use approximately 10 years ago and he states that now he only drinks beer occasionally. He denies any prior history of tobacco use. Family History: His father is alive at the age of 70, in good health. Mother is alive in her 60s, in good health. He has two siblings who appear to be in good health as well. There is no family history of inflammatory bowel disease, cholangiocarcinoma, gastric cancer, colon cancer, prostate cancer, or hepatocellular carcinoma. Physical Exam: Vitals: AVSS Gen: NAD HEENT: NCAT, PERRL, MMM Neck: no LAD CV: RRR, no m/r/g Resp: CTAB Abd: soft, NT,ND Ext: no edema Skin: no rashes Pertinent Results: [2134-3-15] 04:16AM BLOOD WBC-2.2* RBC-3.58* Hgb-12.1* Hct-34.5* MCV-96 MCH-33.7* MCHC-35.0 RDW-14.9 Plt Ct-62* [2134-3-15] 03:14PM BLOOD WBC-3.5# RBC-2.26 Hgb-7.7* Hct-22.1* MCV-98 MCH-34.3* MCHC-35.1* RDW-14.8 Plt Ct-70* [2134-3-15] 09:27PM BLOOD WBC-5.4# RBC-3.30# Hgb-10.9# Hct-30.5# MCV-93 MCH-32.9 MCHC-35.6* RDW-15.6* Plt Ct-93* [2134-3-15] 09:27PM BLOOD WBC-5.4# RBC-3.30# Hgb-10.9# Hct-30.5# MCV-93 MCH-32.9 MCHC-35.6* RDW-15.6* Plt Ct-93* [2134-3-22] 05:10AM BLOOD WBC-5.7 RBC-3.87* Hgb-12.4* Hct-35.4* MCV-92 MCH-32.2* MCHC-35.1* RDW-15.5 Plt Ct-96* [2134-3-15] 04:16AM BLOOD PT-14.4* PTT-32.9 INR(PT)-1.3* [2134-3-19] 05:46AM BLOOD PT-11.9 PTT-31.8 INR(PT)-1.0 [2134-3-22] 05:10AM BLOOD Plt Smr-LOW Plt Ct-96* [2134-3-15] 04:16AM BLOOD Fibrino-130* [2134-3-16] 02:49AM BLOOD Fibrino-259 [2134-3-15] 04:16AM BLOOD Glucose-128* UreaN-17 Creat-0.8 Na-141 K-4.3 Cl-108 HCO3-25 AnGap-12 [2134-3-22] 05:10AM BLOOD Glucose-88 UreaN-23* Creat-1.0 Na-138 K-4.8 Cl-102 HCO3-29 AnGap-12 [2134-3-15] 04:16AM BLOOD ALT-41* AST-51* AlkPhos-138* TotBili-0.7 [2134-3-22] 05:10AM BLOOD ALT-339* AST-71* AlkPhos-118* TotBili-0.8 [2134-3-15] 04:16AM BLOOD Albumin-3.7 Calcium-9.1 Phos-3.4 Mg-1.9 [2134-3-15] 04:16AM BLOOD Albumin-3.7 Calcium-9.1 Phos-3.4 Mg-1.9 [2134-3-22] 05:10AM BLOOD Calcium-9.0 Phos-4.3 Mg-1.5* [2134-3-21] 08:00AM BLOOD Albumin-3.4 Calcium-9.1 Phos-3.6 Mg-1.5* [2134-3-15] 04:16AM BLOOD HBsAg-POSITIVE HBsAb-NEGATIVE HBcAb-POSITIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [2134-3-16] 02:49AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE, [2134-3-18] 05:05AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE [2134-3-19] 05:46AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE,T [2134-3-20] 05:09AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE,T [2134-3-21] 08:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE,T [2134-3-17] 05:12AM BLOOD FK506-3.4* [2134-3-18] 05:05AM BLOOD FK506-9.2 [2134-3-19] 05:46AM BLOOD FK506-9.1 [2134-3-20] 05:09AM BLOOD FK506-8.4 [2134-3-21] 08:00AM BLOOD FK506-7.1 [2134-3-22] 05:10AM BLOOD FK506-10.5 [2134-3-15] 04:16AM BLOOD HCV Ab-NEGATIVE Brief Hospital Course: The patient was admitted [3-15] and underwent orthotopic deceased donor liver transplant, piggyback, portal vein to portal vein anastomosis, common bile duct to common bile duct anastomosis without a T tube, donor common hepatic artery to recipient common hepatic artery end-to-end. Operative findings were notable for a cirrhotic liver with a large lesion in the right lobe of his liver consistent with prior radiofrequency ablation site. The omentum was stuck to this lesion. He had mild portal hypertension. He had no other significant abnormalities. No T tube was placed. Two 19 [Doctor Last Name 406] drains were placed and brought through separate stab incisions. Intraoperatively, the patient received 7000 cc of Plasma-Lyte, 3 units of fresh frozen plasma, 2 units of platelets, 1 unit of cryo, 500 cc of albumin and made 750 cc of urine. The patient was transferred to the surgical intensive care unit in stable condition. A post-transplant ultrasound showed patent transplant vasculature except right hepatic artery not visualized. It also showed higher than normal velocities in the portal vein. CXR - NGT coiled in stomach, Swan in PA, density LLL. HBV DNA non-detectable. On POD 1, an ultrasound was repeated which showed patent hepatic vasculature, with normal waveforms. A 5.5 x 2.7 cm subhepatic collection consistent with postop changes. On POD 7, an ultrasound was again performed which showed all hepatic vessels to be patent. Return of bowel function was noted on POD 2 and the patient's diet was advanced. The lateral drain was removed on POD 4 and a 3-0 silk suture was used to close the site. The medial drain was removed on POD 7. The [Hospital 228] hospital course has been complicated by high blood sugars to the 200's. The patient was changed to a diabetic diet and [Last Name (un) ] was consulted. The patient was placed on a stricter sliding scale and started on a nighttime dose of Lantus. The patient is being discharged on POD 7 with minimal pain, ambulating without difficulty, and tolerating a regular diet. Medications on Admission: Acyclovir 25', Omeprazole 20' Discharge Medications: 1. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Entecavir 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 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. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:30 Tablet(s) Refills:0 10. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime: Also follow sliding scale insulin. Disp:2 bottles Refills:2 11. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Hepatitis B Immune Globulin Injectable Sig: Five (5) ml Intramuscular ONCE (Once): follow schedule. to be given in clinic. 13. Insulin Lispro (Human) 100 unit/mL Solution Sig: follow sliding scale Subcutaneous four times a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: s/p Orthotopic liver transplant [2134-3-15] Discharge Condition: Good Discharge Instructions: Call the transplant office at [Telephone/Fax (1) 673] if you experience any of the following symptoms: fever, chills, nausea, vomiting, diarrhea, inability to eat, pain over the incision site or liver, yellowing of the skin or eyes, an increase in abdominal girth. Monitor incision for redness, drainage or bleeding. Do not drive if you are taking narcotics. Take your medications exactly as directed. Have labs drawn every Monday and Thursday and have them faxed to [Telephone/Fax (1) 697]. CBC, Chem 10, AST, ALT, Alk Phos, Albumin, T Bili and trough Prograf Level Followup Instructions: [Last Name (LF) ],[First Name3 (LF) 156] TRANSPLANT SOCIAL WORK Date/Time:[2134-3-24] 1:00 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2134-3-24] 1:40 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2134-3-31] 3:20 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709]	[ "572.3", "571.8", "070.32", "155.2", "724.2", "E932.0", "251.8", "571.5" ]	icd9cm	[ [ [] ] ]	[ "50.59", "88.72", "00.93", "38.93" ]	icd9pcs	[ [ [] ] ]	8879, 8937	5447, 7522	356, 402	9029, 9036	3244, 5424	9661, 10216	2755, 3074		7602, 8856		8958, 9008		7548, 7579			9060, 9638									3089, 3225																								274, 318										430, 1415															1437, 2019	2035, 2739
11,865	196,482	13005	Discharge summary	report	Admission Date: [2100-10-8] Discharge Date: [2100-10-13] Date of Birth: [2048-12-21] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 51-year-old gentlemen with a known history of coronary artery disease who presented to [Hospital6 256] for elective cardiac catheterization on [2100-10-8]. As of results of catheterization, he is referred to Cardiothoracic Surgery for urgent coronary artery bypass graft. Mr. [Known lastname 39841] had a history of having a percutaneous transluminal coronary angioplasty in [2091]. This past [Month (only) ] while on [Hospital3 ], he has a rescue percutaneous transluminal coronary angioplasty stenting of his distal right coronary artery for acute myocardial infarction. On [10-1], he had an exercise tolerance test/thallium where he exercised for nine minutes of [Initials (NamePattern4) ] [Last Name (NamePattern4) ] protocol and stopped because of fatigue. He had electrocardiogram changes and sharp pain in the early recovery. Ejection fraction was calculated to be 46% and he had a moderate partially reversible inferior defect. He has done well until recently when he began to notice recurrent symptoms. He reports having chest tightness and shortness of breath when exerting himself such as walking up a slight incline. Symptoms resolve with rest. The patient denies any claudication, orthopnea, edema, paroxysmal nocturnal dyspnea, lightheadedness. Coronary artery disease risk factors: Hypertension, cholesterol, tobacco abuse, quit 10 years ago. Denies diabetes, positive family history and patient's father died of an myocardial infarction at age 43. PAST MEDICAL HISTORY: Osteoarthritis, coronary artery disease, status post myocardial infarction, renal stones, recent retinal vein occlusion with minimal carotid artery disease, sleep apnea, presently on CPAP. PAST SURGICAL HISTORY: Status post right shoulder surgery for a rotator cuff injuries, status post surgery for deviated septum. MEDICATIONS ON ADMISSION: Aspirin 325 po q.d., Lipitor 40 mg po q.d., Toprol 100 po q.d., Wellbutrin 150 mg po b.i.d., Prozac 10 mg po b.i.d., Rhinocort 2 puffs q.d., Vitamins, Accupril 10 mg po q.d. ALLERGIES: Sulfa, penicillin, tetracycline cause swelling and rash, shellfish and dye. PHYSICAL EXAMINATION: Vital signs: Heart rate 70. Blood pressure 108/70. General: Appearance, well-dressed, well-nourished gentlemen appearing his stated age in no apparent distress. Head, eyes, ears, nose and throat: No jugular venous distention, carotids without bruits. Lungs: Clear to auscultation bilaterally. Cardiac: Regular rate and rhythm, no murmur. Abdomen: Soft, nontender, nondistended. Neurological: Alert and oriented times three, nonfocal. Extremities: Bilateral peripheral pulses. No varicosities. KEY STUDIES: Results of cardiac catheterization from [2100-10-17]: 1. Left anterior descending with 50% diffuse proximal and 60-70% diffuse mid vessel disease, 80% proximal stenosis of the first diagonal. Left circumflex has diffuse disease and 70% stenosis of the first obtuse marginal. The right coronary artery has 30% mid vessel and 50% focal occlusion. 2. Resting hemodynamics revealed mildly elevated systolic and left ventricular filling pressures. 3. Left ventriculography revealed mild anterolateral hypokinesis and severe posterobasal inferior hypokinesis with an ejection fraction of 35%. 4. Successful percutaneous transluminal coronary angioplasty of OM1 with type C dissection. BRIEF SUMMARY OF HOSPITAL COURSE: The patient was referred to Dr. [Last Name (STitle) 70] for an emergent coronary artery bypass graft. Patient was brought to the Operating Room on the evening of [2100-10-17]. Coronary artery bypass graft times four vessels and anastomosis between his left internal mammary artery to the left anterior descending artery. Radial artery graph was used as a conduit to the first obtuse marginal artery. Saphenous vein graft was used for an anastomosis to the diagonal and a saphenous vein graft was used in anastomosis to the right posterior descending artery. The patient tolerated the procedure well and was brought from the Operating Room to the Intensive Care Unit on propofol, nitroglycerin and Neo-Synephrine drip. In the Intensive Care Unit, the patient was extubated on the first postoperative day, but remained on a Neo-Synephrine drip until postoperative day number two, when the Neo-Synephrine was able to be weaned off. Once Neo-Synephrine was taken off, patient had his PA catheter course introducer removed. On postoperative day number three, the patient was transferred to the Patient Care Floor. By the time the patient reached the floor, his chest tubes had been removed. On postoperative day number four, the patient was out of bed and ambulating to a level 3, tolerating a diet and his pacer wires were removed. By postoperative day number five, the patient was ambulating at a level 5 and was tolerating a full diet. His pain was controlled and was voiding and felt ready to go home. DISPOSITION: Discharged home. CONDITION OF DISCHARGE: Stable. DISCHARGE MEDICATIONS: 1. Lasix 20 mg po b.i.d. times one week. 2. KCL 20 mg po b.i.d. while on Lasix. 3. Colace 100 mg po b.i.d. 4. Aspirin 81 mg po q.d. 5. Imdur 30 mg po q.d. 6. Lipitor 40 mg po q.d. 7. Ibuprofen 400-600 mg po q. 6 hours. 8. Percocet 1-2 tablets po q. 4-6 hours. 9. Wellbutrin 150 mg po b.i.d. 10. Prozac 10 mg po q.d. 11. Lopressor 50 mg po b.i.d. FOLLOW-UP: The patient will follow-up with Dr. [Last Name (STitle) ], his primary care physician, [Name10 (NameIs) ] three weeks and will see Dr. [Last Name (STitle) 70] in Clinic in six weeks. DISCHARGE DIAGNOSIS: Status post coronary artery bypass graft, four vessels including left internal mammary artery to left anterior descending, radial artery to OM1, saphenous vein graft to D1, saphenous vein graft to right posterior descending artery. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Last Name (NamePattern1) 6355] MEDQUIST36 D: [2100-10-15] 22:57 T: [2100-10-15] 22:57 JOB#: [Job Number 39842]	[ "412", "780.9", "E947.8", "996.09", "429.9", "414.01", "272.0", "401.9", "411.1" ]	icd9cm	[ [ [] ] ]	[ "36.01", "39.61", "88.72", "88.56", "42.23", "36.13", "36.15", "36.06", "37.22" ]	icd9pcs	[ [ [] ] ]									5201, 5765		5787, 6324		2052, 2316											1919, 2025											3592, 5178			2339, 3562																					158, 1682															1705, 1895
46,884	164,104	40543	Discharge summary	report	Admission Date: [2174-6-9] Discharge Date: [2174-7-13] Date of Birth: [2119-5-23] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 14802] Chief Complaint: Pulmonary venous ablation complicated by right temporo-parietal ICH Major Surgical or Invasive Procedure: [2174-6-9] Right craniotomy evacuation of right ICH [2174-6-11] Decompressive right craniectomy, evacuation of right ICH [2174-6-16] Tracheostomy [2174-6-29] EG feeding tube History of Present Illness: Ms. [Known lastname ] is a 55 yo F with h/o PAF and SVT who initially presented for isolated pulmonary venous ablation. She was intubated and heparinized prior to procedure. During the procedure, she had AVNRT and her ACT was 500. Per verbal report, blood pressures were transiently as high as 200 mmHg during the procedure. Pericardial tap revealed 90cc's of bloody fluid but no effusion on intracardiac echo. Her anticoagulation was reversed at the end of the procedure. Patient was transferred to CCU for observation after the procedure. On arrival to the CCU, patient was found to be somnolent and not responding to commands, not moving her right leg. She began to complain of a headache. STAT head CT revealed large temporo-parietal IPH with 4mm midline shift. Neurosurgery was called to assess the patient. On initial evaluation by neurosurgery, patient was found to be somnolent, eyes opening to loud voice and sternal rub. She was moaning, complaining of headache, not following commands. She was able to state her last name only. Face was symmetric and pupils were equal and reactive. She spontaneously moved her upper extremities and left leg, right leg not moving. Past Medical History: 1. Paroxysmal atrial fibrillation; irregular palpitations, associated with dyspnea and fatigue for the last 5 years. PAF noted on Holter with RVR up to 100-150 bpm. Can last up to 24 hours. Treated with Atenolol, Diltiazem, and Flecainide which have all been discontinued due to inefficacy and fatigue. Usually occurs three or four times a month, usually lasting 24 hours, with associated palpitations and some labored breathing, and resolves spontaneously. 2. Palpitations x 20 years 3. SVT since her 20's; regular rapid palpitations with presyncope at onset and self terminates within a few seconds. No actual syncope. Holter [2172] demonstrated narrow complex tachycardia at 25 bpm with 1:1 VA relationship and short PR interval and negative p waves. Occurs more during menstruation and with prior pregnancies. Very infrequent, once a month or so. 4. Normal EF by echo [2173-2-16] with LVEF of 55-60% and no significant valvular abnormalities. 5. Normal stress test [2172] Social History: She lives at home with her husband and has 5 kids, all of whom are of young adult age. She is a lifelong nonsmoker. She does not drink caffeine and rarely has any alcoholic beverages. She is of [Doctor First Name ] faith. Family History: Brother has atrial fibrillation diagnosed in his 50's. Father was diagnosed with atrial fibrillation in his 80's. Physical Exam: ADMISSION PHYSICAL EXAM: -Gen: Eyes shut, opens to loud voice and occasional and sternal rub -HEENT: Pupils: 5-3.5 bilateral reactive EOMs unable to test -Neck: Supple. -Mental status: Moans complains of headache, mumbles, was able to state last name only. Does not follow any commands. -Cranial nerves: Face appears symmetric and tongue is midline -Strength: Spontaneously moving upper extremities briskly. Noted to wiggle left foot not moving lower extremities to command. Has bil knee immobilizers in place. Toes downgoing bilaterally . DISCHARGE PHYSICAL EXAM: EO to voice, restless, fluent spontaneous speech but confused and with waxing/[Doctor Last Name 688] attentiveness. RUE purposeful and follows commands, some movment LUE to noxious. Moves BLE spontaneously. Pertinent Results: NONCONTRAST HEAD CT ([2174-6-9], 5:36 PM): 1. Right frontoparietal and left parietal parenchymal hematomas with fluid-fluid levels. Mild vasogenic edema surrounding the largest hematoma in the right temporoparietal lobe with approximately 5 mm leftward shift of midline structures. Intraventricular and subarachnoid extension of bleed, without hydrocephalus. 2. No evidence of brain herniation. POST-CRANIOTOMY NONCONTRAST HEAD CT ([2174-6-9], 11:20 PM): 1. Status post partial evacuation of a right temporoparietal parenchymal hematoma with expected post-surgical changes. Stable intraventricular extension of hemorrhage, with mild increase in the intraventricular component. 2. Mild increase in the left frontal parenchymal hematoma. 3. Stable leftward shift of midline structures TRANSTHORACIC ECHO ([2174-6-10]): The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. NONCONTRAST HEAD CT ([2174-6-10]): 1. Status post partial evacuation of right temporoparietal parenchymal hematoma, with stable appearance of the residual hematoma. Interval increase in the surrounding vasogenic edema, mass effect and leftward shift of midline structures which is now approximately 6 mm, previously 4mm. Left high frontal hematoma, although similar, shows mild increase in the surrounding vasogenic edema. 2. Stable intraventricular extension of hemorrhage, with mild dilatation of the left lateral ventricle, as before. NONCONTRAST HEAD CT ([2174-6-11]): 1. Again, noted is minimal increase in surrounding vasogenic edema of the right temporoparietal parenchymal hematoma with the hematoma itself appearing stable in size. There is mild increased effacement of the adjacent right lateral ventricle, there is leftward shift of the normally midline structures by 6 mm. 2. Stable intraventricular extension of the hemorrhage with mild dilatation of left lateral ventricle. POST-CRANIECTOMY HEAD CT ([2174-6-11]): 1. Status post right frontoparietal craniectomy with outpouching of frontoparietal parenchyma through the calvarial defect. 2. New frontoparietal 2.5 x 2.0 cm hematoma with surrounding vasogenic edema. 3. Stable size of right temporo-parietal parenchymal hematoma and left frontal hematoma with stable intraventricular extension of hemorrhage. Mild increase in surrounding vasogenic edema. 4. Leftward shift of the normally midline structures now measures 3 mm, prior 6 mm. NONCONTRAST HEAD CT ([2174-6-15]): 1. Increased herniation of more edematous brain parenchyma through the right parieto-occipital craniotomy, without evidence of new or increasing hemorrhage. Stable mild leftward shift of the midline structures. 2. Stable left frontal hemorrhage with mild surrounding edema. 3. Stable intraventricular hemorrhage with no evidence of developing hydrocephalus. 4. Stable right frontal hypodensities without new foci of hemorrhage. PORTABLE CXR ([2174-6-15]): worsening of left lower lobe atelectasis. Right pleural effusions larger on the right side have markedly decreased. BLE DOPPLERS ([2174-6-16]): Negative for DVT bilaterally PORTABLE CXR ([2174-6-16]): Tracheostomy tube, nasogastric tube, and left subclavian catheter are in standard positions. There is no interval change in left lower lobar atelectasis and small-to-moderate left pleural effusion but otherwise clear lungs. No pneumothorax is seen with normal cardiomediastinal contours. PORTABLE CXR ([2174-6-17]): 1. The Dobbhoff feeding tube now courses below the stomach with tip projecting over the expected location of the stomach. Left subclavian central line has its tip in the mid SVC, unchanged, and tracheostomy tube remains in satisfactory position. 2. Stable cardiac and mediastinal contours. The lungs are relatively well inflated. There is suggestion of paucity of vessels in the apices, which may represent underlying emphysema. There is increasing airspace opacity at both bases which may reflect pulmonary edema, although worsening pneumonia or aspiration would be also of concern. Clinical correlation is advised. No pneumothorax is seen on the right. The left cannot be adequately assessed given the absence of the apex on this image. PORTABLE CXR ([2174-6-19]): Worsening multifocal airspace opacities, concerning for multifocal pneumonia in the appropriate clinical setting. NONCONTRAST HEAD CT ([2174-6-19]): Apparent interval increase lateral herniation of brain through the right frontoparietal craniotomy. Stable distribution of left frontal and right frontoparietal hematomas with associated edema and left intraventricular hemorrhage, as well as concurrent subarachnoid component. EEG ([2174-6-20]): This is an abnormal continuous ICU monitoring study because of continuous focal slowing, breach artifact, and frequent epileptiform discharges in the right posterior quadrant. These findings are indicative of a potentially epileptogenic focal structural lesion and skull defect in the right posterior quadrant. Over the left hemisphere, the alpha rhythm is slow and there is excess diffuse theta activity. There are also frequent brief runs of frontal intermittent rhythmic delta activity. These findings are indicative of mild to moderate diffuse cerebral dysfunction, which is etiologically nonspecific. There are no electrographic seizures. PORTABLE CXR ([2174-6-20]): Progressive consolidation, right lower lobe, initially developing on [6-17] is pneumonia. Previous left lower lobe collapse has resolved. Feeding tube ends in the stomach. Heart size top normal. Pulmonary vascular congestion is mild, borderline pulmonary edema has improved. Tracheostomy tube in standard placement. EEG ([2174-6-21]): This is an abnormal continuous ICU monitoring study because of continuous focal slowing, breach artifact, and frequent epileptiform discharges in the right posterior quadrant. These findings are indicative of a potentially epileptogenic focal structural lesion and skull defect in the right posterior quadrant. Over the left hemisphere, the alpha rhythm is slow and there is excess diffuse theta activity. There are also frequent brief runs of frontal intermittent rhythmic delta activity. These findings are indicative of mild to moderate diffuse cerebral dysfunction, which is etiologically nonspecific. There are no electrographic seizures. Compared to the prior day's recording, epileptiform activity is less frequent, but there is no other change. EEG ([2174-6-22]): This is an abnormal continuous ICU monitoring study because of continuous focal slowing, attenuation of faster frequencies and breach artifact in the right posterior quadrant. These findings are indicative of a focal structural lesion and skull defect in the right posterior quadrant. Over the left hemisphere, the alpha rhythm is slow and there is excess diffuse theta activity. There are also frequent brief runs of frontal intermittent rhythmic delta activity. These findings are indicative of mild to moderate diffuse cerebral dysfunction which is etiologically non-specific. There are no electrographic seizures. Compared to the prior day's recording, epileptiform activity is no longer seen. EEG ([2174-6-23]): This is an abnormal continuous ICU monitoring study because of continuous focal slowing, attenuation of faster frequencies and breach artifact in the right posterior quadrant. These findings are indicative of a focal structural lesion and skull defect in the right posterior quadrant. Over the left hemisphere, the alpha rhythm is slow and there is excess diffuse theta activity. There are also frequent brief runs of frontal intermittent rhythmic delta activity. These findings are indicative of mild to moderate diffuse cerebral dysfunction, which is etiologically nonspecific. There are no electrographic seizures. Compared to the prior day's recording, there is no significant change. EKG ([2174-6-23]): Atrial fibrillation with rapid ventricular response. Diffuse non-specific ST-T wave changes. Compared to the previous tracing of [2174-6-23] atrial fibrillation has now appeared. PORTABLE CXR ([2174-6-23]): Improving but persistent right lower lung pneumonia, with near complete resolution of pneumonia in the left base. EEG ([2174-6-24]): This is an abnormal continuous ICU monitoring study because of continuous focal slowing, attenuation of faster frequencies and breach artifact in the right posterior quadrant. These findings are indicative of a focal structural lesion and skull defect in the right posterior quadrant. Over the left hemisphere, the alpha rhythm is slow, there is excess diffuse theta activity, and there are frequent brief runs of frontal intermittent rhythmic delta activity (FIRDA). These findings are indicative of mild to moderate diffuse cerebral dysfunction, which is etiologically nonspecific. There are no electrographic seizures. Compared to the prior day's recording, there is no significant change. NONCONTRAST HEAD CT ([2174-6-24]): 1. Evolution of hemorrhagic products within right fronto-parietal-temporal parenchyma and left frontal lobe with similar surrounding vasogenic edema. 2. Improved left occipital [Doctor Last Name 534] hemorrhage. Resolution of subdural hematoma along the falx. 3. Similar degree of subarahnoid hemorrhage especially along the left cerebral hemisphere. 4. Unchanged herniation of the right hemispheric parenchyma. 5. Hypodensity in the right temporal region likely representing edema versus subacute infarct is evolved since [2174-6-15]. 6. Opacification of right mastoid. PORTABLE CXR ([2174-6-24]): Right basal consolidation continues to clear, now almost radiographically undetectable. Lungs are otherwise clear. Heart is normal size. Persistent effacement of the aortopulmonic window since the end of [Month (only) ] be a normal anatomic variant, or could be due to adenopathy in that location, even though I see no indication of adenopathy elsewhere in the mediastinum. Neither is there any pleural abnormality. Tracheostomy tube is in standard placement. Feeding tube ends in the upper stomach. Left PIC line tip projects at the origin of the SVC. EEG ([2174-6-25]): This is an abnormal continuous ICU monitoring study because of frequent electrographic seizures, continuous focal slowing, attenuation of faster frequencies and breach artifact in the right posterior quadrant. These findings are indicative of an epileptogenic focal structural lesion and skull defect in the right hemisphere, with seizures arising from the right central region. The electrographic seizures occur predominantly in a cluster between 3:20 and 4:20 AM, although there are rare seizures at other times. The seizures are brief, lasting less than 20 seconds, and have no clinical correlate. Over the left hemisphere, there is predominantly theta and delta activity. There are also abundant brief runs of frontal intermittent rhythmic delta activity. These findings are indicative of moderate diffuse cerebral dysfunction, which is etiologically nonspecific. Compared to the prior day's recording, there are now frequent electrographic seizures arising from the right central region, with a total of approximately 15 seizures, mostly between 3 and 4 AM. There is also more slowing and rhythmic delta activity over the left hemisphere, indicating worsening of diffuse cerebral dysfunction. EEG ([2174-6-26]): This is an abnormal continuous ICU monitoring study because of frequent focal electrographic seizures arising from the right central region. There is continuous focal slowing, attenuation of faster frequencies and breach artifact in the right posterior quadrant. These findings are indicative of an epileptogenic focal structural lesion and skull defect in the right posterior quadrant. Over the left hemisphere, the alpha rhythm is slow and there is excess diffuse theta activity. There are also frequent brief runs of frontal intermittent rhythmic delta activity and occasional triphasic waves. These findings are indicative of mild to moderate diffuse cerebral dysfunction, which is etiologically nonspecific. Compared to the prior day's recording, right central electrographic seizures are less frequent, particularly at the end of the study, and the left hemisphere shows faster frequencies. EEG ([2174-6-27]): This is an abnormal continuous ICU monitoring study because of rare focal seizures, continuous focal slowing, attenuation of faster frequencies and breach artifact in the right posterior quadrant. The seizures arise from the right central region (C4). Three seizures last less than 20 seconds; a fourth lasts 3 minutes. None of the seizures show an clinical correlate on video. These findings are indicative of an epileptogenic focal structural lesion and skull defect in the right posterior quadrant. Over the left hemisphere, the alpha rhythm is slow and there is excess diffuse theta activity. There are also occasional brief runs of frontal intermittent rhythmic delta activity. These findings are indicative of moderate diffuse cerebral dysfunction, which is etiologically nonspecific. Compared to the prior day's recording, electrographic seizures are less frequent. The one longer seizure had no clinical correlate. RUQ ULTRASOUND ([2174-6-26]): Normal right upper quadrant ultrasound. NONCONTRAST HEAD CT ([2174-6-27]): 1. Postsurgical changes related to right temporoparietal craniectomy. Parenchymal herniation through the craniectomy defect appears improved since [2174-6-24] exam. Areas of intraparenchymal, subarachnoid, and intraventricular hemorrhage are largely unchanged since prior exam. No new area of intracranial hemorrhage is detected. 2. No evidence of hydrocephalus, however, ventricular caliber has increased since [2174-6-19] exam. EEG ([2174-6-28]): This is an abnormal continuous ICU EEG monitoring study because of a single focal electrographic seizure, continuous focal slowing, attenuation of faster frequencies and breach artifact in the right posterior quadrant. The brief seizure arises from the right central region (C4). There is no clinical correlate on video. These findings are indicative of an epileptogenic focal structural lesion and skull defect in the right posterior quadrant. Over the left hemisphere, the alpha rhythm is slow and there is excess diffuse theta activity. There are also occasional brief runs of frontal intermittent rhythmic delta activity. These findings are indicative of moderate diffuse cerebral dysfunction, which is etiologically nonspecific. Compared to the prior day's recording, electrographic seizures are less frequent, and the overall background activity has improved. EEG ([2174-6-29]): This is an abnormal continuous ICU EEG monitoring study because of continuous focal slowing, attenuation of faster frequencies and breach artifact in the right posterior quadrant. These findings are indicative of a focal structural lesion and skull defect in the right posterior quadrant. Over the left hemisphere, the alpha rhythm is slow and there is excess diffuse theta activity. There are also occasional brief runs of frontal intermittent rhythmic delta activity. These findings are indicative of moderate diffuse cerebral dysfunction which is etiologically non-specific. Compared to the prior day's recording, no electrographic seizures are seen. EEG ([2174-6-30]): This is an abnormal continuous ICU EEG monitoring study because of continuous focal slowing, attenuation of faster frequencies and breach artifact along with an electrographic seizure arising from the right central region. These findings are indicative of a focal epileptogenic structural lesion and skull defect in the right hemisphere. The alpha rhythm is slow and there is excess diffuse theta activity on the left. There are also occasional brief runs of frontal intermittent rhythmic delta activity. These findings are indicative of moderate diffuse cerebral dysfunction, which is etiologically nonspecific. Compared to the prior day's recording, one 7 minute long electrographic seizure is seen along with three other runs of rhythmic activity in the right central region which do not clearly show evolution in frequency or morphology. EEG ([2174-7-1]): This is an abnormal continuous ICU EEG monitoring study because of continuous focal slowing, attenuation of faster frequencies and breach artifact in the right central region. These findings are indicative of a focal potentially epileptogenic structural lesion and skull defect in the right hemisphere. The alpha rhythm is slow and there is excess diffuse theta activity on the left. There are also occasional brief runs of frontal intermittent rhythmic delta activity. These findings are indicative of moderate diffuse cerebral dysfunction, which is etiologically nonspecific. Compared to the prior day's recording, no electrographic seizures are present, but there are still right central epileptiform discharges. VIDEO SWALLOW ([2174-7-4]): Some penetration of nectar-thick liquids and residue in vallecula. No aspiration was noted. NONCONTRAST HEAD CT ([2174-7-6]): 1. Established cystic encephalomalacia and white matter abnormality, likely a combination of edema and gliosis, in the right temporoparietal region. 2. Overall extent of edema appears unchanged. 3. Decreased mass effect on the occipital [Doctor Last Name 534] of the right lateral ventricle. Video swallow [2174-7-12] Possible penetration with thin liquids. Otherwise, normal oropharyngeal swallowing videofluoroscopy. Somewhat limited exam due to patient movement. Dilantin level 22.7 corrected Brief Hospital Course: 55 yo F with h/o PAF and SVT who initially presented for pulmonary venous ablation which was complicated by right temporo-parietal ICH with intraventricular extension. #RIGHT TEMPORO-PARIETAL ICH: Patient was taken urgently to OR for right craniotomy and evacuation of right ICH. Post-op head CT showed partial evacuation with expected post-surgical changes and mild increase in intraventricular extension, stable leftward midline shift (MLS). Patient was transferred to the ICU. Overnight she had anisocoria; repeat head CT showed mildly inceased vasogenic edema and small increase in MLS (4mm->6mm). She was extubated on AM of HD #2 and was able to clear her secretions. Over the course of the day she slowly became more responsive, speaking and moving her right side but still with a moderate left hemiparesis. On HD#3, her LLE became more paretic and her mental status worsened. Repeat head CT was performed showed worsening midline shift, so patient was given mannitol 50g IV x1 and taken urgently to OR for decompressive craniectomy. Post-operatively she was started on hyperosmolar therapy with 3% NS, and 3-day IV decadron taper. Post-op head CT showed improvement in leftward MLS (6mm->3mm), but new right frontoparietal 2.5x2cm hematoma with vasogenic edema. By HD #7, patient was able to open eyes to command. Her sutures were removed on POD #13; incision appeared clean/dry/intact. Craniectomy could not be performed during hospitalization due to persistent transcalvarial edema; EEG was negative for seizures and neurology felt that she was safe for discharge. She will need outpatient follow-up with her neurosurgeon Dr. [Last Name (STitle) ] for this procedure. # S/P PULMONARY VENOUS ABLATION: Patient's cardiac enzymes downtrended appropriately after her procedure. Follow-up TTE was negative for significant pericardial effusion or wall motion abnormality; LVEF 60-65%. On HD #5 patient had an episode of AFi with RVR to 130s. She was converted to sinus with IV lopressor and IV dilt. She then returned to AFib so started amiodarone bolus and drip, and metoprolol was increased to 50mg IV TID. She continued to have multiple runs of Afib between HD [2-23] which were managed with diltiazem and metoprolol boluses; after this she spontaneously converted to sinus rhythm. Per cardiology recs, her med regimen on discharge was amiodorone 100mg PO daily, metoprolol tartrate 75mg PO BID. ASA 81mg daily was also restarted on HD#28 with permission from neurosurgery. Patient will follow up as outpatient with Dr. [Last Name (STitle) ] [Name (STitle) ]. # NONCONVULSIVE SEIZURES: Patient was initially placed on Keppra for seizure prophylaxis due to the cortical location of her ICH. Due to persistently depressed mental status in the ICU, continuous EEG was started on HD #12, which initially showed diffuse cerebral dysfunction with epileptiform discharges but no seizures. Her Keppra was uptitrated to 150mg PO BID and she was started on Dilantin. Dilantin was briefly held while patient febrile (concern for drug fever), but on HD #16 EEG showed frequent seizures (no clinical seizure on video EEG) so she was re-loaded with dilantin and started on a TID dose. On discharge, her anti-epileptic regimen is Keppra 1500mg PO BID + Dilantin 100mg PO TID. Corrected dilantin level on discharge is 22.7. # DELIRIUM: While patient's mental status and neuro exam continued to slowly improve during hospitalization, her sleep-wake cycle was persistently deranged and she developed delirium superimposed on her organic brain injury. This was managed with supportive care and medications (will be discharged on Seroquel for sleep); expect this to resolve as she transitions out of the hospital environment. # ID: Patient had persistent fevers during her ICU stay, initially treated empirically for VAP with vanc/cefepime/tobramycin, then narrowed to cefazolin when urine cultures showed a pan-sensitive E. coli UTI. She completed her course of antibiotics, but then developed a second UTI with pan-sensitive pseudomonas, so underwent a second antibiotic course with IV cefepime for a 7-day course (completed on [7-8]). # RESPIRATORY: Patient suffered from respiratory failure secondary to her neurologic deficits causing inability to tolerate secretions. Tracheostomy was performed on HD #8 with placement of Passey-Muir valve for speech. # GI: Patient repeatedly failed bedside swallow evaluations and initially required tube feeds via NGT. PEG tube was placed on HD#21, and patient began continuous and then cycled tube feeds. On HD#26 she had video swallow which showed she was no longer aspirating so her diet was advanced to ground solids and nectar-thickened liquids. Video swallow on [7-12] was improved. See results and diet instructions ============================== TRANSITION OF CARE: -Please check Dilantin level on [2174-7-15] as a trough prior to am dose. Goal level is 15-20. Medications on Admission: ASA 325mg daily Discharge Medications: 1. Amiodarone 100 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Metoprolol Tartrate 75 mg PO BID HOLD for SBP<100, HR<55 4. Sarna Lotion 1 Appl TP QID:PRN pruritis apply to abdomen 5. Miconazole Powder 2% 1 Appl TP QID:PRN Irritation perineal 6. Senna 1 TAB PO BID Constipation 7. Heparin 5000 UNIT SC TID 8. Acetaminophen 650 mg PO Q6H:PRN pain 9. Bisacodyl 10 mg PO/PR DAILY Constipation 10. Docusate Sodium (Liquid) 100 mg PO BID 11. Albuterol 0.083% Neb Soln 1 NEB IH Q8H:PRN chest tightness 12. HydrOXYzine 25 mg PO Q6H:PRN itching 13. LeVETiracetam 1500 mg PO BID 14. Quetiapine Fumarate 25-50 mg PO QHS:PRN insomnia 15. Phenytoin (Suspension) 100 mg PO Q8H Discharge Disposition: Extended Care Facility: [Last Name (un) ] institute for rehabilitation Discharge Diagnosis: paroxysma atrial fibrillation right MCA infarct Right ACA infarct Left frontal ICH Cerebral Edema with uncal herniation Transcalvarium herniation right intracerebral hemorrhage Intraventricular hemorrhage mental status change hypernatremia seizures dysphagia respiratory failure requiring trach urinary tract infection VAP Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms. [Known lastname ], You were admitted to the hospital for a pulmonary venous ablation to treat your cardiac arrythmia. Your procedure was complicated by a brain hemorrhage. You underwent emergent craniotomy with evacuation of the hemorrhage, followed by hemicraniectomy (removal of half the skull to release pressure on the brain). You had a tracheostomy (breathing tube in the neck) and PEG feeding tube placed. You had seizures caused by the brain bleed so you were placed on anti-epileptic medications. You are now being discharged to rehab where you will work closely with physical therapy to continue the recovery process. You will need to return to [Hospital3 ] in [12-20] months to be evaluated for repair of your craniotomy. Please schedule the recommended follow-up appointments with cardiology and neurosurgery (see below for phone numbers). Other instructions: ??????Please wear your helmet at all times when you are up and out of bed. ??????Have a friend or family member check your craniectomy site for signs of infection such as redness or drainage daily. ??????Take your pain medicine as prescribed if needed. You do not need to take it if you do not have pain. ??????Exercise should be limited to walking; no lifting >10lbs, straining, or excessive bending. ??????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. ??????DO not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. until follow up. ??????Do not drive before your second surgery. Dilantin level should be checked on [7-15] as a trough prior to am dosing. Followup Instructions: -Please call Dr. [Last Name (STitle) ] [Name (STitle) ] ([Telephone/Fax (1) 88772]) to schedule cardiology and electrophysiology follow-up within the next month. He plans to come to rehab for your follow-up appointment. -Please call the Neurosurgery Department ([Telephone/Fax (1) 88773]) to schedule a follow-up appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] within 1-2 months after discharge. You will need a head CT scan prior to your appointment, which can be scheduled when you call to make the follow-up appointment. Completed by:[2174-7-13]	[ "E879.8", "041.11", "431", "427.31", "276.0", "041.49", "599.0", "427.89", "348.5", "423.9", "434.91", "997.31", "342.90", "348.4", "780.39", "310.9", "997.02", "518.51" ]	icd9cm	[ [ [] ] ]	[ "37.0", "96.72", "01.25", "37.34", "33.24", "01.39", "31.1", "38.97", "37.27", "96.6", "37.26", "43.11" ]	icd9pcs	[ [ [] ] ]	28037, 28114	22352, 27287	376, 568	28481, 28481	3980, 22329	30447, 31059	3050, 3166		27353, 28014		28135, 28460		27313, 27330			28658, 30424						3486, 3722			3206, 3352																								269, 338										596, 1779											28496, 28634				1801, 2791	2807, 3034				3747, 3961
18,510	138,684	16621	Discharge summary	report	Admission Date: [2180-11-21] Discharge Date: [2180-12-11] Date of Birth: [2134-12-22] Sex: M Service: MICU HISTORY OF THE PRESENT ILLNESS: The patient is a 46-year-old gentleman with alcoholic cirrhosis/hepatitis who had recently been discharged on [2180-11-17] after an upper GI bleed secondary to variceal bleeding. He had variceal banding times five. Since his discharge, the patient had increasing fatigue and somnolence. His family noticed that he was confused the night prior to admission. He was seen in the Liver Clinic on the day of [2180-11-21] and was found to have an elevated BUN and creatinine. His creatinine was 1.8, up from a baseline of 0.8. His total bilirubin was also noted to be up. The patient was sent to the Emergency Department. In the Emergency Department, he was found to be hypotensive with a blood pressure of 80/palpable. He was given 1.5 liters of IV fluids and his systolic blood pressure increased to 100. The patient denied fevers, chills, night sweats, chest pain, shortness of breath. He stated that he had a productive cough. He had no nausea, vomiting, diarrhea. He had one to two bowel movements per day. He had noticed no change in his abdominal swelling or leg swelling. PAST MEDICAL HISTORY: 1. Alcoholic cirrhosis/hepatitis. 2. Variceal bleed status post banding. 3. Malnutrition. 4. Alcohol abuse. MEDICATIONS AT HOME: 1. Nadolol 20 mg p.o. q.d. 2. oxpentifylline 400 mg p.o. t.i.d. 3. Ursodiol 250 mg p.o. t.i.d. 4. Protein 40 b.i.d. 5. Lactulose titrated, two to four stools per day. 6. Levaquin 500 mg p.o. q.d. 7. Multivitamin. 8. Combivent. 9. Thiamine 100 mg p.o. q.d. ALLERGIES: Penicillin. SOCIAL HISTORY: The patient has a history of alcohol abuse. He drinks approximately 750 cc of whiskey per day. He is a current drinker. He is also a current smoker. He has a 15 pack year history of smoking. The patient lives alone and has one son. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 96.5, blood pressure 90/50, heart rate 75, respiratory rate 20, saturating 95% on room air. The patient was alert and oriented and was in no apparent distress. He was grossly jaundiced. HEENT: Positive icteric sclerae. The pupils were equal and reactive to light bilaterally. Mucous membranes were moist. There was no thrush. Pulmonary: There were left lower lobe rales. There was diffuse wheezing. CVS: Regular rate and rhythm. S1 and S2 were normal. There were no murmurs. Abdomen: The abdomen was distended. There was shifting dullness. The abdomen was nontender. There was no organomegaly. Extremities: There was 3+ pitting edema bilaterally. Skin: Spider angiomata present. Neurological: There was no asterixis. LABORATORY DATA ON ADMISSION: White count 28.9, hematocrit 34.5, platelets 376,000. Sodium 134, potassium 3.2, chloride 99, bicarbonate 20, BUN 32, creatinine 2.2, glucose 68, ALT 31, AST 126, amylase 96, alkaline phosphatase 319, bilirubin 3.9, albumin 2.6, lipase 128. INR 1.2, PT 18.2, PTT 51.7. A thoracentesis revealed an albumin of 0.6 and 75 white blood cells. A urinalysis was negative for blood and nitrates. There was a trace of leukocyte esterase. There were trace ketones. Urobilinogen was 0.2. There were no white cells or red cells. Urine sodium was 37. The patient was hepatitis B surface antigen negative, hepatitis A negative, [Doctor First Name ] negative. Blood cultures were taken in the Emergency Room. A right upper quadrant ultrasound showed a fatty liver. There was no ductal dilation. The bile ducts were 7 mm. There was a sluggish portal vein flow. There was no thrombus. Chest x-ray showed fluid in the right fissure and a possible left lower lobe infiltrate. HOSPITAL COURSE: The patient was admitted to the Medicine Team. 1. GASTROINTESTINAL: The patient had a recent history of an upper GI bleed prior to admission. On admission, he was noted to have an increasing bilirubin. A right upper quadrant ultrasound on admission was negative. The patient was initially maintained on Octreotide, pentoxifylline and Actigall. His hematocrit was followed b.i.d. He was also continued on Lactulose for hepatic encephalopathy. The patient did not do well on the floor and was eventually transferred to the ICU for management of his hypotension. While in the ICU, he developed an upper GI bleed. He was electively intubated to undergo EGD. This revealed varices but no bleeding. The patient was maintained in the ICU. His liver function continued to worsen. He eventually developed hepatorenal syndrome. 2. RENAL: The patient was admitted with acute renal failure. He was followed in the hospital by the Renal Service. Initially it was felt that his renal failure could be secondary to ATN from his hypotension versus hepatorenal syndrome. The patient's MAPs were maintained over 75 to maintain kidney perfusion. He eventually required two pressors to achieve this blood pressure. However, his renal function continued to decline. It is likely that his renal failure was secondary to hepatorenal syndrome. 3. CARDIOVASCULAR: The patient was hypotension at admission with a systolic blood pressure in the 90s. This was responsive to fluid boluses. However, several days into his admission the patient again became hypotensive. He was transferred to the MICU for further management. A Swan was placed. The patient was given pressors to maintain an MAP of greater than 70-75. This helped maintain his urine output. The pressors were attempted to be weaned off several times. However, the patient was unable to tolerate this. After several weeks in the ICU, it was apparent that the patient was developing multisystem failure, as his blood pressure had no signs of improvement, his kidneys were failing and he was unable to maintain a blood pressure without two pressors. His family decided to pursue comfort measures. The pressors were stopped and the patient's blood pressure dropped. The patient died the next day. 4. INFECTIOUS DISEASE: The patient was initially admitted with a high white count but no fever. He was started on ceftriaxone, vancomycin, and Flagyl. The patient completed a 14 day course of vancomycin, ceftazidime, and Flagyl. He was maintained on Flagyl for prophylaxis for his liver disease. He was also maintained on Fluconazole for empiric coverage of fungal organisms. The patient was paracentesed approximately every three days while in the hospital. This was mostly for comfort. However, none of these cultures revealed any organism. The patient's blood cultures remained negative while in the hospital. 5. PULMONARY: The patient was electively intubated on [2180-11-29] for an EGD. We were unable to wean him off the ventilator subsequent to that. Several times the patient was able to be maintained on pressor support only. However, after approximately one day each time the patient required assist control ventilator settings. Eventually the patient's family decided to make him comfort measures only and he was extubated. A died a short time afterwards. The patient was bronchoscoped on [2180-12-9]. This was done after a chest x-ray showed decreased volume in the right upper lobe. A large mucus plug was removed with resolution of the decreased volume in the right upper lobe. 6. HEMATOLOGY: The patient was anemic at baseline. His hematocrits were followed closely while in the hospital. He was transfused packed red blood cells several times while in the hospital. Towards the end of his admission, he was requiring transfusions of packed cells approximately every one to two days. The patient also received FFP and cryoprecipitates prior to every procedure, approximately every three days. The patient was also maintained on vitamin K p.o. while in the hospital. 7. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient received tube feeds while in the hospital. Initially, a postpyloric feeding tube was placed by the Interventional Radiology Service. Unfortunately, this was dislodged during his EGD. For a few days the patient was maintained on a nasogastric feeding tube. After a few days, Interventional Radiology replaced his postpyloric feeding tube. The patient's electrolytes were monitored and repleted q.d. 8. NEUROLOGY: The patient's mental status waxed and waned while in the hospital. This was likely secondary to encephalopathy. He was maintained on Lactulose during his stay in the hospital. We felt that the patient was unable to make decisions and, therefore, his family was consulted for medical decision making. 9. PROPHYLAXIS: The patient was maintained on pneumo boots and Protonix while in the hospital. 10. CODE STATUS: Initially the patient was DNR, but not DNI. As his condition worsened, several family meetings were held with his two sisters, [Name (NI) 1258] and [Name (NI) 5969], as well as his brother in-law. After much discussion, given his bleak prognosis, the family decided to pursue comfort measures. On [2180-12-10], the pressors were stopped. The patient became very hypotensive to the 20s. On the morning of [2180-12-11], his family decided to extubate the patient. The patient passed away several minutes later. DISCHARGE DIAGNOSIS: 1. Alcoholic cirrhosis/hepatitis. 2. Ascites. 3. End-stage liver disease. 4. Acute renal failure, likely secondary to hepatorenal syndrome. 5. Upper gastrointestinal bleed. 6. Cardiovascular collapse. 7. Respiratory distress secondary to mucous plug. 8. Coagulopathy. 9. Transfusion-dependent anemia. 10. Malnutrition. 11. Encephalopathy. [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 7585] Dictated By:[Last Name (NamePattern1) 9681] MEDQUIST36 D: [2180-12-21] 02:13 T: [2180-12-21] 15:34 JOB#: [Job Number 47099]	[ "572.2", "518.0", "584.9", "263.9", "518.82", "785.51", "572.4", "571.2", "789.5" ]	icd9cm	[ [ [] ] ]	[ "96.6", "45.13", "96.72", "34.91", "96.04", "54.91", "33.23" ]	icd9pcs	[ [ [] ] ]							1988, 2027				9364, 9974			3835, 9343						1426, 1717																																																2841, 3817						1292, 1405	1734, 1971
19,798	171,202	27657	Discharge summary	report	Admission Date: [2112-1-1] Discharge Date: [2112-1-6] Date of Birth: [2052-10-25] Sex: M Service: CARDIOTHORACIC Allergies: Tetracycline Attending:[Last Name (NamePattern1) 1561] Chief Complaint: A history of Oligometastatic (brain) Hilarly located, Right Upper Lobe Non-small Cell Lung Cancer s/p previous chemo/xrt now presents for definitive surgical management of his primary lung cancer Major Surgical or Invasive Procedure: 1- Flexible Bronchoscopy, Right Thoracotomy, Right Upper Lobe Sleeve Resection, Primary Bronchoplasty, Intercostal Muscle Flap ([2112-1-1]) History of Present Illness: Mr. [Known lastname ] is a 59yo M w/ a PMHx of HTN, CAD/MI ('[06]), GERD/esophagitis who presented ~ 6 months prior to this admission for work-up of a RUL lung cancer. He was foound to have a large, hilar based, non-small cell lung cancer of the right upper lobe causing compression/obliteration of the superior segment bronchus. Metastatic work-up included PET imaging and a brain MRI revealing a metastatic focus to his brain that necessitated craniotomy and cyberknife therapy (cyberknife was done to the surgical bed when it was thought that he recurred). Ultimately, he [Year (2 digits) 1834] a platinum based neoadjuvant chemo/XRT regimen for his primary lung cancer and serial CT imaging showed no evidence of disease progression. A pre-operative bronchoscopy w/ washings and mediastinoscopy still showed that the disease was only locally advanced and a likely Stage IIIa hilar based NSLC was opted for surgical therapy. On [2112-1-1], he was admitted for a Right Thoracotomy, Right Upper Lobe Sleeve Resection with Primary Bronchoplasty and Intercostal Muscle Flap. Past Medical History: NSCLC (oligometastatic to the brain) Hypercholesterolemia Coronary artery disease (MI in [2106] with sent placement) No HTN, DM or COPD Past Oncolgic History: Diagnosed with NSCLC by transbronchial biopsy on [2111-6-4]. Staging MRI revealed solitary brain metastasis in the left frontal region for which he [Date Range 1834] Cyberknife in mid-[2111-8-4]. Social History: He has financial concerns regarding cost of care. He is married. He lives with his wife. [Name (NI) ] does not have any children. He is a home broker. He reports smoking two packs of cigarettes a day for 40 years and quiting two months ago. He currently drinks about three to four drinks a week. He does not have any other exposures that he knows of. Family History: Grandfather died of lung cancer (non-smoking related). Mother died of myocardial infarction. Father died of brain cancer. He has 3 brothers who are alive but a fourth died of complications of hepatitis C. He does not have children. Physical Exam: VS: T= 98.1 HR= 72 (sinus) BP= 122/78 RR= 20 SpO2= 98%RA HEENT- old healed craniotomy scar appreciated, no cervical/supraclavicular adenopathy, no neck mass/bruit, neck supple, OP (-) Cor- Regular S1S2 Pulm- CTA bilaterally Abd- soft, NT, ND, no HSM, no mass/hernia Ext- no c/c/e/ct, 2+DP/PT bilaterally Neuro- moves all extremities, normal strength/sensation throughout, CNII-XII intact, DTRs normal Pertinent Results: [2112-1-1] 03:07PM HGB-10.1* calcHCT-30 O2 SAT-96 Brief Hospital Course: Mr. [Known lastname ] [Last Name (Titles) 1834] a R-thoracotomy, RUL lobectomy w/ sleeve resection, primary bronchoplasty and intercostal muscle flap coverage. The patient did well intraoperatively and was resuscitated with 2 units of PRBCs (EBL ~ 600cc) as well as several liters of isotonic crystalloid. He was transferred to the CSRU for further care after extubation in the OR. Post-operatively, he had an epidural, foley, chest tubes x2 in the r-hemithorax, an arterial line and peripheral IV access. Neuro- his pain control was adequate with a thoracic epidural which was ultimately removed on POD#4 and converted to an oral regimen; he had no evidence of delerium/anxiety-NOS; per-operative ambien/zyprexa were continued at his home doses. Pulmonary- His chest tubes were removed on POD#3 with no demonstration of air leak and outputs less than 150cc q24hr interval. Post-removal chest film demonstrated satisfactory position of the lung with adeuate expansion, minimal effusion and no real volume overload. He was saturating well on room air with ambulation prior to dismissal. Cardiovascular- he developed Afib w/ a RVR ~ 36hrs post-operatively necessitating ICU transfer and neosynephrine/amiodarone supplementation. He had no evidence of coronary ischemia by ECG and his relative hypotension experienced during the acute setting of the Afib was asymptomatic. Ultimately, he was transitioned to an oral regimen of amiodarone and beta blockade and converted to sinus rhythm. FEN/GI- he was maintained on protonix for stress-ulcer prophylaxis (he takes it chronically) and was able to tolerate a regular, heart-healthy diet by POD#1. GU/Renal- His BUN/Cr remained normal during his peri-operative course and his foley was rmeoved on POD#4 after the thoracic epidural was taken out. He was maintained on his home dose of flomax, as well. He was diuresed for a number of days post-operatively, however, he never significantly demonstrated a weight gain post-operatively and he had no major oxygenation/ventilation problems. Endocrine- he was transiently given SSIR for peri-operative glycemic control/prophylaxis HEME/ID- he remained afebril with no outstanding infectious disease issues during his post-operative convalescence. He received 2 additional doses of kefzol immediately post-operatively and his surgical site incisions appeared C/D/I. His pre-operative Hct = 30, he was transfused 2 units intraoperatively and a total of 2 untis were transfused for Blood Loss Anemia during his 5 day post-operative course. Medications on Admission: Keppra 500mg po BID, Toprol XL 50mg po QD, ambien 5mg po HS prn, zyprexa 5mg po HS, aspirin (stopped pre-operatively), protonix 40mg po QD, Lipitor 20mg po QD, Flomax 0.4mg po QD Discharge Medications: 1. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for PRN insomnia. 2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): as long as you are taking narcotics; to avoid constipation. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 12. HYDROmorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed. Disp:30 Tablet(s) Refills:0 13. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). 14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: 1-Right Upper Lobe Oligometastatic Hilar Non-Small Cell Lung cancer s/p R-thoracotomy, Right Upper Lobe Sleeve Resection with Primary Bronchoplasty and Intercostal Muscle Flap ([2112-1-1]) 2- Post-operative atrial fibrillation (with Rapid Ventricular Response) 3- Hypertension (controlled) 4- Coronary artery disease/myocardial infarction (remote, controlled) 5- GERD/Esophagitis (remote) Discharge Condition: Stable, afebrile, adequate analgesia with oral medications, wounds healing well, in normal sinus rhythm Discharge Instructions: You may resume your home medications as previously instructed. Please use the list from the hospital to determine how and [Last Name (un) 4050] to take your medications for the first few weeks after surgery (there may be some new medications that you take for a short-interval after your operation to help with controlling your heart rhythm). No heavy lifting, swinging or exertion for 3-4 weeks. You should take walks (3-4 per day for 15-20 minute intervals) You may shower and pat the wound dry with a towel but no swimming, bath tub, whilrpool for 2-3 weeks. You should call the office if you experience any new redness, drainage, swelling, pain, shortness of breath, difficulty breathing, fever > 101F, shaking chills or productive cough. Followup Instructions: Please call the clinic to confirm your appointment; you should return in [1-5] weeks post-operatively and have a chest xray on the same day prior to seeing Dr. [Last Name (STitle) 952].	[ "V45.82", "162.3", "414.01", "530.81", "272.0", "285.1", "427.31", "401.9", "412" ]	icd9cm	[ [ [] ] ]	[ "33.48", "40.3", "32.4", "34.21", "33.22" ]	icd9pcs	[ [ [] ] ]	7484, 7490	3288, 5834	482, 628	7927, 8033	3208, 3265	8831, 9028	2539, 2772		6063, 7461		7511, 7906		5860, 6040			8057, 8808									2787, 3189																								247, 444										656, 1752															1774, 2148	2164, 2523
808	139,077	3776	Discharge summary	report	Admission Date: [2181-5-11] Discharge Date: [2181-5-16] Date of Birth: [2126-6-27] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor First Name 1402] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Pericardial drainage. Thoracentesis. History of Present Illness: 54 y/o female w/ PMH moderate hypertension, remote h/x of asthma presenting to CCU after pericardiocentesis. Patient reports onset of right sided flank pain 6wx ago. Last few weeks began noticing DOE. Trouble catching the bus and going up stairs. PCP sent her for CXR which showed cardiomegally and vascular congestion. [Doctor First Name ] today revealed cardiac tamponade. Went to cath lab for pericardiocentesis and right heart catheterization. Past Medical History: Tuberculosis treated in [2145] with normal chest x-ray at [Hospital1 2025] in [2162]. G2 P2. Tubal ligation [2156]. Hypertension. History of mild asthma, inhalers not used for several years. Perimenopausal. Social History: She works as a nursing assistant. Lives with her husband, who keeps very early hours, working at the [Location (un) ] food market. Children are 18 and 19. Family History: Her father died of stomach cancer at age 72. Mother died of colon cancer at age 63. She is the 10th of 13 children. She has lost 3 siblings to motor vehicle accidents. Physical Exam: VS: T:98.2 BP:149/94 HR:103 RR: 20 O2: 98%RA Gen: NAD, looks stated age. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 5 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Lung exam notable for decreased BS on rihgt and RLL crackles. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [2181-5-11] 12:18PM BLOOD WBC-3.8* RBC-5.64* Hgb-18.0* Hct-53.1* MCV-94 MCH-31.9 MCHC-33.9 RDW-13.2 Plt Ct-283 [2181-5-15] 06:45AM BLOOD WBC-5.4 RBC-5.49* Hgb-17.5* Hct-50.9* MCV-93 MCH-31.8 MCHC-34.3 RDW-13.4 Plt Ct-179 [2181-5-11] 12:18PM BLOOD PT-12.8 PTT-27.0 INR(PT)-1.1 [2181-5-15] 06:45AM BLOOD PT-12.7 PTT-26.6 INR(PT)-1.1 [2181-5-11] 12:18PM BLOOD Glucose-112* UreaN-10 Creat-0.8 Na-141 K-4.0 Cl-103 HCO3-25 AnGap-17 [2181-5-15] 06:45AM BLOOD Glucose-109* UreaN-10 Creat-0.8 Na-137 K-4.0 Cl-103 HCO3-23 AnGap-15 [2181-5-12] 04:29AM BLOOD ALT-20 AST-18 LD(LDH)-161 AlkPhos-132* Amylase-28 TotBili-1.0 [2181-5-12] 04:29AM BLOOD Albumin-4.0 Calcium-9.5 Phos-4.4 Mg-2.2 [2181-5-15] 06:45AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.3 [2181-5-13] 05:20AM BLOOD TSH-6.1* [2181-5-14] 05:21AM BLOOD Free T4-1.7 [2181-5-12] 04:59AM BLOOD [Doctor First Name ]-POSITIVE Titer-1:40 [2181-5-13] 05:20AM BLOOD C3-147 C4-42* . Pericardial Fluid Obtained [2181-5-11]: (Note some of these samples are erroneously labeled as ascitic fluid in the OMR. Also please note that this sample was lost in the lab from [5-11] to [2181-5-14]. Processing began thereafter) [2181-5-11] 03:30PM OTHER BODY FLUID WBC-3400* RBC-7850* Polys-1* Lymphs-29* Monos-13* Mesothe-15* Macro-42* TotPro-8.9 Glucose-0 LD(LDH)-1186 Amylase-15 Albumin-5.0 GRAM STAIN 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Pending): ACID FAST SMEAR (Pending): ACID FAST CULTURE (Pending): FUNGAL CULTURE (Pending): ANAEROBIC CULTURE (Pending): . Pericardial Fluid Obtained after multiple saline flushes when the drain itself was being removed [2181-5-13]: (Note some of these samples are erroneously labeled as ascitic fluid and though all obtained on [5-13] some are mislabled as being obtained on [2181-5-12] in the OMR) 07:17PM ASCITES WBC-875* RBC-8500* Polys-73* Lymphs-1* Monos-26* GRAM STAIN 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Final [2181-5-14]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Pending): . Pleural Fluid Obtained [2181-5-14]: WBC-1000* RBC-1875* Polys-39* Lymphs-38* Monos-10* Eos-2* Meso-5* Macro-4* Other-2* TotProt-5.6 Glucose-106 LD(LDH)-305 GRAM STAIN (Final [2181-5-14]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Pending): ANAEROBIC CULTURE (Pending): ACID FAST SMEAR (Pending): ACID FAST CULTURE (Pending): Adenosine Deaminase pending: . [2181-5-10] CXR:IMPRESSION: Interval cardiomegaly and fluid overload indicating mild cardiac failure. Small right pleural effusion. Followup examination is recommended after appropriate clinical interval. Findings discussed with Dr. [First Name (STitle) ] by telephone at time of interpretation. . [2181-5-11] Cardiac [Month/Day/Year ] Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is a moderate to large sized pericardial effusion. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology; the right ventricle also appears compressed. There is significant, accentuated respiratory variation in mitral valve inflows, consistent with impaired ventricular filling. . [2181-5-14] Cardiac [Month/Day/Year ] Conclusions: Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. There is a small (1-1.5cm; ?loculated pericardial effusion around the right atrium. No effusion is seen around the right ventricle or left ventricle. Compared with the prior study (images reviewed) of [2181-5-12], the ?loculated effusion around the right atrium is slightly larger, but hemodynamic compromise is not suggested. . [2181-5-15] Lower extremity Non-invasives.... Brief Hospital Course: This is a 54 year old woman with a past medical history significant for treated tuberculosis as a child and mild hypertension who presented to her PCP with shortness of breath. A PA and Lateral chest x-ray revealed cardiomegaly and an admission cardiac [Month/Day/Year ] revealed a pericardial effusion with tamponade physiology. A pericardial drain was placed which relieved the patient's symptoms. The patient also had a large right sided pleural effusion which was drained. Neither fluid contained any organisms on gram stain (including specific stains for tuberculosis). Cultures had not grown anything at the time of discharge. [First Name8 (NamePattern2) 6] [Doctor First Name ] was checked and felt to be non-specific at 1:40. A TSH was elevated at 6.1 but the free T4 was normal at 1.7. The patient was never febrile and she never developped an elevated white blood cell count. . Again, the patient's dyspnea resolved with drainage of her pericardial fluid. She did have some pain at the pericardial drainage and thoracentesis sites for which she was treated with percocet. She was noted to have an elevated hematocrit, which was thought to be unrelated to her pericarditis. It was determined that she should follow up with her PCP regarding this issue. On the day of discharge the patient complained of pain in her calves bilaterally. She had spent a significant time in bed and there was some concern for venous thromboembolism, so she was sent for bilateral lower extremity ultrasound. The results of this demonstrated a distal DVT. As it was symptomatic, she was started on lovenox and coumadin as discussed with her PCP. [Name10 (NameIs) 15110] to frequent urination and boarderline hyponatremia she was discontinued on HCTZ and began on Amlodipine. She was discharged with a follow [Name10 (NameIs) 113] and follow up appointments with her PCP and the attending cardiologist. Medications on Admission: HCTZ 25mg po QDAY Albuterol prn (used only recently, not for 1-2 years prior) Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:10 Tablet(s) Refills:0 2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff Inhalation every six (6) hours as needed for shortness of breath or wheezing. Discharge Disposition: Home Discharge Diagnosis: Idiopathic Percarditis with cardiac tamponade. Idiopathic Pulmonary Effusions. Discharge Condition: Vital signs are stable. Respiratory status improved. Satting well on room air. Discharge Instructions: Please take your medications as prescribed. Please follow up with the appointments that we set up for you. Please note that Dr. [First Name (STitle) ] does not want you to return to work until you have seen her on [2181-5-23]. . Please come back to the hospital if you should develop chest pain or shortness of breath. You have just been admitted to the hospital with a serious condition. If you should develop any symptoms that are concerning to you Followup Instructions: Provider: [Name10 (NameIs) ] LAB TESTING Phone:[Telephone/Fax (1) 128] Date/Time:[2181-5-22] 9:00 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 250] Date/Time:[2181-5-23] 11:30 Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 677], M.D. Phone:[Telephone/Fax (1) 2934] Date/Time:[2181-7-25] 1:00	[ "511.9", "453.42", "V12.01", "276.51", "493.90", "401.9", "420.91" ]	icd9cm	[ [ [] ] ]	[ "37.21", "88.55", "34.91", "37.0" ]	icd9pcs	[ [ [] ] ]	9392, 9398	6948, 8872	324, 363	9521, 9603	2235, 3786	10112, 10543	1284, 1453		9001, 9369		9419, 9500		8898, 8978			9627, 10089									1468, 2216																						4957, 6925		277, 286										392, 845										4424, 4531					867, 1092	1108, 1268		4374, 4388
48,913	197,286	13954	Discharge summary	report	Admission Date: [2130-10-19] Discharge Date: [2130-10-27] Service: NEUROLOGY Allergies: Celebrex / Lisinopril / Norvasc / Iodine; Iodine Containing Attending:[Last Name (NamePattern1) 1838] Chief Complaint: Poor balance and nausea with vomiting. Major Surgical or Invasive Procedure: None History of Present Illness: The pt is a 87 year-old right-handed female, with history of Afib on Coumadin, hypertension, and hypothyroidism who had 2 weeks of worsening balance and fatigue who was unable to get up from the toilet 6:30am ont he morniing of admission. She called out for help and her daughter who lives with her came into assist her. She found the patient to be leaning to her right and assisted her to the living room. She was able to eat breakfast but soon felt nauseated and when she returned to the bathroom, she vomitted several times. She was even weaker than before, leaning on her daughter more hence EMS was called. No reported trauma or complains of headache. Patient was brought by EMS to [Hospital3 ] where she was noted to be in afib. Her head CT revealed a left cerebellar hemorrhage. Initial INR was 3.1. She was started on FFP, given VitK 2mg prior to her transfer to [Hospital1 18] for further evaluation. Past Medical History: 1. Afib (dx 2 yrs ago). Cardioconvert attempted last [Month (only) 404], unsuccessful - on Coumadin; followed per Dr. [Last Name (STitle) 41722] [Name (STitle) 17976] at [Hospital1 756]. 2. hypertension greater than 5 yrs. 3. hypothyroid > 5 yrs. 4. MI (stents placed last year) 5. Breast cancer s/p L mastectomy plus radiation therapy at age 74 yrs old Social History: Lives with two daughters in [Name (NI) 392]. Able to perform basic daily living skills but has aide who stays with her for safety while daughters are at work. Family History: Non-contributory Physical Exam: Vitals: T: P: 20 R:64 BP:155/58 SaO2:NC 2lit 98% 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: Arouses to voice and can respond verbally. Oriented to TPP, unable to relate history. Decreased attention span but redirectable. Language is fluent with intact comprehension. There were no paraphasic errors. Able to read without difficulty. Speech was slightly dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. Cranial Nerves: Olfaction not tested. Anisocoria - s/p cataract surgery bilaterally, right pupil reactive (4 to 3 mm), left pupil reactive (1 1/2 mm to 1 mm). Left eye ptosis, EOMI without nystagmus. Normal saccades. Facial sensation intact to LT. No facial droop, facial musculature symmetric. Hearing intact grossly bilaterally. Tongue protrudes in midline. Motor: Normal bulk, tone throughout. Formal strength testing limited due to level of alertness and cooperation. Spontaneous movement of all extremities agaist gravity and some resistance, symmetrical and bilateral, UE & LE. Sensory: No deficits to light touch, 2 pt and cold sensation. Coordination: unable to asses due to limited cooperation alertness. Reflex: No clonus [Hospital1 ] Tri Bra Pat An Toes C5 C7 C6 L4 S1 CST L2 2 2 2 2 mute R2 2 2 2 2 mute Gait: not assesed for safety reasons. Neurological Examination prior to discharge Mental Status: Alert to time, place and person. However, does not remember the year. Cranial nerves: intact Motor: No pronator drift, full strength of the arms, questionable weakness in the bilateral IPs. She had intention tremor of the left greater than right with FNF testing. Needs the assistance of one person to stand. PT has walked her with a walker. Pertinent Results: CT Scan on [2130-10-19]: There is a 2.3 x 2.1 cm area of increased attenuation within the left lobe of the cerebellum with some central hypoattenuation. There is mild surrounding edema. There is mild mass effect, although the fourth ventricle is patent without more proximal hydrocephalus. There is cerebral atrophy and small vessel ischemic change. Included paranasal sinuses and mastoid air cells are clear. There are no fractures. MRI/A on [2130-10-20]: Left cerebellar hemorrhage measuring 2.1 X 2.4 cm, associated with mild mass effect on the fourth ventricle. Areas of chronic microvascular ischemic changes. There is no evidence of acute ischemic event. Prominence of the sulci and ventricles, likely age related and involutional in nature. There is evidence of vascular flow in both internal carotids as well as the vertebrobasilar system. The vessels demonstrate segmental areas of narrowing, more evident on the left M1 segment and diffuse narrowing in both medial cerebral arteries, also the basilar artery demonstrate minimal segmental narrowing likely consistent with diffuse atherosclerotic disease. MRA with Contrast [2130-10-22]: Unchanged appearance of left cerebellar hemorrhage with surrounding edema and mild mass effect. No new hemorrhage, ischemia, or hydrocephalus. Following administration of gadolinium contrast, there is no evidence for abnormal enhancement. [2130-10-27] CBC WBC-6.4 RBC-3.19* Hgb-11.0* Hct-31.2* MCV-98 MCH-34.4* MCHC-35.1* RDW-14.7 Plt Ct-190 [2130-10-26] [2130-10-27] 06:45AM BLOOD Glucose-93 UreaN-22* Creat-1.3* Na-140 K-3.5 Cl-99 HCO3-33* AnGap-12 [2130-10-26] 07:00AM BLOOD Glucose-88 UreaN-23* Creat-1.2* Na-142 K-3.5 Cl-99 HCO3-33* AnGap-14 Brief Hospital Course: Patient is a 87yo RHW with hx of Afib on Coumadin, HTN, hypothyroidism and hx of breast cancer s/p L mastectomy here with 2 weeks of being "off-balance, leaning more to right" and being acutely more unbalanced and weak with nausea and vomitting on the morning of admission who was found to have 2.1 X 2.4 cm L cerebellar hemorrhage more likely secondary to HTN and anticoagulation. She was supra-therapeutic since INR on admission was 3.1. She was initially admitted under neurosurgery service given the significant cerebellar hemorrhage. Although there was some effecement of the 4th ventricle, there were no signs of increased signs of ICP. She was then switched to neurology service and remained well without HA, nausea/vomitting or visual disturbance. MRI and MRA without contrast were performed. There were no signs of ischemic infarct or AVM/aneurysms. Then MRI brain was repeated WITH contrast on [10-22]. There was enhancement of the border of the left cerebellar hemorrhage but this was thought to be consistent with hemorrhage. The enhancement pattern was not suggestive of a neoplasm. There was less effacement of the 4th ventricle. She was restarted on ASA 81mg daily on [10-27] for cardiac stent and stroke prevention. The issue of restarting coumadin was discussed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] with Dr. [First Name8 (NamePattern2) 3075] [Last Name (NamePattern1) 17976] ([Hospital1 756]), her cardiologist, the patient, and her daughters. Based on the risk of recurrent hemorrhage with resumption of Coumadin and the patient's preference, coumadin was not restarted. Patient will have a repeat MRI brain with contrast in [3-28] weeks to re-evaluate whether there could be a neoplasm underlying the cerebellar bleed. Medications on Admission: -Colace 100mg [Hospital1 ] -ferrous sulfate 325mg daily -avapro 300mg qd -syntroid 100mcg qam -omeprazole 20mg qam -senna tabs 2 tabs [Hospital1 ] -ASA EC 81mg qd -lipitor 40mg qpm -caltrate 2 tabs [Hospital1 ] -peri colace 100mg [Hospital1 ] -metoprolol succ ER 150mg qpm -coumadin 2mg (mon-wed-fri-sat-sun); 3mg (tues-thurs) Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Irbesartan 300 mg Tablet Sig: One (1) Tablet PO QD (). 5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 10. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 11. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal [Hospital1 ] (2 times a day) as needed for hemorrhoids. 12. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY (Daily) as needed. 13. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN (as needed) as needed for for hemorrhoids. 14. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 15. PERI-COLACE Oral Discharge Disposition: Extended Care Facility: [Hospital 66] Rehabilitation and Nursing Center Discharge Diagnosis: Left cerebellar hemorrhagic stroke Hemorrhoids Constipation Discharge Condition: While in bed, neurologically stable with normal language, essentially full strength (mild weakness of bilateral IPs, ?R delt), drift upwards bilaterally, L>R intention tremor with mild rest tremor as well. However, she was requiring the assistance of one to transfer to a chair. She needs a rollator frame to mobilize. She does have short-term recall problems. However, she would benefit from physiotherapy for her rehab needs. Discharge Instructions: You have had a stroke. If you experience sudden weakness, loss of consciousness, problems with speech, you should go to the nearest emergency room. Please call to arrange follow up appointments. Take all medications as prescribed. Followup Instructions: 6-8 weeks time with Dr [Last Name (STitle) ] [Last Name (NamePattern5) ], please call to schedule an appointment([Telephone/Fax (1) 41723] Completed by:[2130-10-27]	[ "584.9", "244.9", "427.31", "348.5", "403.90", "564.09", "496", "412", "790.92", "414.01", "E934.2", "585.9", "455.3", "428.0", "V10.3", "431", "V58.61", "V45.82" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	9452, 9530	5897, 7702	317, 323	9634, 10064	4147, 5874	10344, 10527	1866, 1884		8096, 9429		9551, 9613		7728, 8073			10088, 10321									1899, 2406																								239, 279										351, 1276	3871, 4128										3785, 3855				1298, 1670	1686, 1850
75,251	101,194	37528	Discharge summary	report	Admission Date: [2189-12-4] Discharge Date: [2189-12-10] Date of Birth: [2114-4-27] Sex: M Service: MEDICINE Allergies: Levaquin / Shellfish Derived / Latex / Aranesp Attending:[First Name3 (LF) 2297] Chief Complaint: Chest pain, shortness of breath Major Surgical or Invasive Procedure: N/A History of Present Illness: 75 yo M hx CAD s/p recent NSTEMI, a. fib not on Coumadin, and recent hospitalization for SIRS [2189-11-20] - [2189-11-30] without obvious source of sepsis presenting from [Hospital6 ] with severe chest pain. He said that this chest pain started 8pm last night, right-sided, non-pleuritic, continuous, sharp, [7-6]. He was initially brought to [Hospital6 33] with SOB and hypotension to 70/50 with CXR showing pneumonia. He was subsequently transferred to [Hospital1 ]. . In the ED, initial vs were: 96 90 124/70 19 100% NRB (which was weaned down to 97% NC 2-3L. His chest pain had resolved by the time of arrival, and pressure initially in the low 100s before decreasing to the 80s. He was started on vancomycin and zosyn, RIJ placed and started on low dose levophed. He received 2L fluid. Past Medical History: 1) CAD (cath in [2161] showed 3-vessel disease, patient states he had MI [09] years ago), presented last hospitalization with NSTEMI believed to be secondary to demand 2) Atrial fibrillation (not on coumadin given h/o GI bleeding) 3) [Company 1543] Kappa KDR701 dual-chamber placement 4) Cirrhosis (classified as cryptogenic although patient has history of heavy EtOH use 35 years ago) 5) Chronic kidney disease with baseline Cr 2.7 6) Angiodysplasia of stomach and small intestine with serial endoscopic cauterization ([2186]) 7) GI bleeding chronic anemia (multifactorial, thought to be [12-29] kidney disease + GI bleeding) 8) Prior TIA ([4-3], ? [8-5]) 9) Melanoma, right forearm 10) Multiple BCCs 11) Diverticulosis 12) Colon polyps 13) Left carotid stenosis with stent ([2184]) 14) BPH ([3-4]) 15) Gout 16) Pneumonia ([12-3]) 17) Portal gastropathy 18) Low grade esophageal varices 19) Remote appendectomy Social History: Lives independently across the street from his daughter. Smoked 1.5 packs/day x 15 years, quit 35 years ago. Former heavy EtOH use, sober x 35 years. No drugs. patient previously worked as a letter carrier for the United States Postal Service. Family History: Notable for MI; Both parents lived to be > [Age over 90 ] years old. Physical Exam: Patient expired during this hospitalization. He was without heart sounds, without breath sounds, without spontaneous movement and without corneal reflex at the time of death at 12:20pm [2189-12-10]. Pertinent Results: [12-8] Abd ultrasound 1. No evidence of portal vein thrombosis. 2. There is grossly heterogeneous echotexture of the hepatic parenchyma with [Month/Year (2) ] architecture related to the patient's history of cirrhosis. 3. There is a questionable hypoechoic area in the right lobe of the liver. A liver lesion cannot be completely ruled out in that area given the limited quality of this portable U/S study. 4. Moderate amount of ascites and a right moderate pleural effusion. [12-7] Echo Suboptimal image quality. Moderate pulmonary artery systolic hypertension. Mildly dilated right ventricular cavity with low normal systolic function. Mild symmetric left ventricular hypertrophy with preserved global and regional systolic function. Trivial pericardial effusion. Compared with the prior study (images reviewed) of [2189-11-25], the right ventricular cavity is now slightly dilated with low normal systolic function and the estimated pulmonary artery systolic pressure is higher. This constellation of findings is suggestive of a primary pulmonary process (e.g., pulmonary embolism, etc.) [2189-12-9] 02:58PM BLOOD WBC-6.4 RBC-2.74* Hgb-9.3* Hct-29.4* MCV-107* MCH-33.8* MCHC-31.5 RDW-21.5* Plt Ct-43* [2189-12-9] 02:58PM BLOOD Neuts-93.1* Lymphs-4.7* Monos-2.2 Eos-0 Baso-0 [2189-12-9] 02:58PM BLOOD Plt Ct-43* [2189-12-6] 04:53AM BLOOD Fibrino-359 [2189-12-5] 11:00AM BLOOD FDP-10-40* [2189-12-9] 02:58PM BLOOD Glucose-143* UreaN-77* Creat-3.3* Na-143 K-5.2* Cl-113* HCO3-17* AnGap-18 [2189-12-9] 05:09AM BLOOD ALT-48* AST-36 LD(LDH)-236 AlkPhos-168* TotBili-2.5* [2189-12-5] 11:00AM BLOOD proBNP-5939* [2189-12-9] 05:09AM BLOOD FSH-3.6 LH-2.8 [2189-12-6] 12:30PM BLOOD Cortsol-15.7 [2189-12-6] 11:09AM BLOOD Cortsol-13.5 [2189-12-6] 11:07AM BLOOD Cortsol-5.4 [2189-12-8] 11:55PM BLOOD Type-ART pO2-93 pCO2-38 pH-7.26* calTCO2-18* Base XS--9 Brief Hospital Course: 75 yo M hx CAD s/p recent NSTEMI, a. fib not on Coumadin, and recent hospitalization for SIRS now with pneumonia on CXR and hypotension. In the MICU patient with worsening renal failure, encephalopathy, without clear source of infection. Medical team spoke with family, and the decision was made to make the patient CMO. . # Altered Mental Status: Patient had progressive decline of mental status throughout admission, and the etiology was multifactorial likely include hepatic encephalopathy, ICU delirium, and infection. Patient was initially put on lactulose and zyprexa. His sleep wake cycle was normalized. . # Hypotension/tachycardia/hypothermia: Unclear etiology, and likely related with SIRS. No clear source identified throughout work up. Patient was initially covered with broad spectrum antibiotics with early goal directed therapy. Cultures were persistently negative. He also underwent pituitary and more central workup - the cortical stim was somewhat abnormal, but other findings were negative. He remained on pressors and was taken off when the decision was made to make him CMO. . # Acute on Chronic Kidney Disease: Crt to 3.2 without clear etiology. Urine with increase in whites/red blood cells. Most likely related to relative hypotension. Started HRS therapy yesterday without improvement. . # SBP. Repeat diagnostic para with 4 white blood cells. This was initially suspected as a possible source of the patient's infection as initial diagnostic para was borderline positive. It was not consistent with the patient's presenting symptoms, however. Patient was initially covered by antibiotics for treatment. . # Right pleural effusion. Patient had a chronic right pleural effusion, but could not lower out a right lower lobe pneumonia. Etiology of the effusion likely to be hydrothorax, however. Patient was covered with antibiotic treatment. . # Chest pain/recent NSTEMI. Chest pain had resolved. Enzymes flat. No EKG Changes. . # End stage liver disease. Labeled crytogenic but patient with previous heavy alcohol use. . # Pancytopenia. Thrombocytopenia likely [12-29] liver disease. Platelets stable. HIV negative. Medications on Admission: - Clotrimazole cream to buttocks - Docusate 100 [Hospital1 ] - FeSO4 325 before lunch - Furosemide 20 [Hospital1 ] - Levothyroxine 50 before breakfast - MVI daily - Omeprazole 20 before breakfast - Senna 2 daily - Simvastatin 80 qhs - Sodium bicarb 650 [Hospital1 ] - TBC Spray topically to heels - Acetaminophen prn - Bisacodyl prn - Sarna prn - Hydrocortisone 2.5% q12h - Lactulose prn - Sorbitol prn Discharge Medications: Patient expired; Discharge Disposition: Expired Discharge Diagnosis: Patient expired; Primary diagnosis: - SIRS Discharge Condition: Patient expired; Discharge Instructions: Patient expired; Followup Instructions: Patient expired; Completed by:[2189-12-10]	[ "518.81", "V45.01", "285.1", "172.6", "287.5", "427.31", "585.9", "280.0", "410.72", "486", "414.01", "537.82", "303.90", "995.91", "571.2", "038.9", "403.90", "599.70", "511.9" ]	icd9cm	[ [ [] ] ]	[ "38.91", "54.91" ]	icd9pcs	[ [ [] ] ]	7347, 7356	4696, 5029	340, 345	7444, 7462	2756, 4673	7527, 7575	2443, 2518		7306, 7324		7377, 7395		6867, 7283			7486, 7504									2533, 2737																								269, 302										373, 1189								7414, 7423			5044, 6841				1211, 2166	2182, 2427
10,809	124,286	21981	Discharge summary	report	Admission Date: [2154-6-30] Discharge Date: [2154-7-18] Date of Birth: [2077-7-30] Sex: M Service: CARDIOTHORACIC Allergies: Tape / Piperacillin Attending:[Last Name (NamePattern1) 1561] Chief Complaint: recurrent tracheobroncheomalacia s/p tracheoplasty [2153-11-12]. admitted for re-do Major Surgical or Invasive Procedure: re-do tracheoplasty [2154-7-1] History of Present Illness: The patient is a delightful 76-year-old gentleman who suffered from acquired tracheal bronchomalacia for several years and underwent a right thoracotomy was with tracheal bronchoplasty with mesh by Dr. [Last Name (STitle) 952] within the past year. He did well within the first several months but unfortunately developed recurrent tracheal bronchomalacia, likely due to the use of Vicryl absorbable sutures which absorbed before the mesh was able to incorporate. The patient redeveloped his symptoms. He returned for a re-do tracheobroncheoplasty w/ mesh. Past Medical History: * s/p tracheobronchoplasty [2153-11-12] * s/p CABGx4 [2129] * tracheomalacia [2139] * trach placed [2149], reversed [2152] with stent placed [2152] * frequent pneumonias, on chronic antibiotics * s/p ccy * s/p hernia repair * s/p bilateraly hip replacement Social History: no smoking, rare ethanol, lives with wife in [Name (NI) 9012], works part-time as CPA Family History: noncontributory Physical Exam: General: robust appearing 76 yr old male in NAD RA sat 96%. HEENT: MMM, PERRL, EOMI. CV: RRR S1, S@. No murmur. Lungs: decreased breath sounds bilat. No wheezes, rhonchi, or crackles ABD: large, round, soft, NT, ND, +BS Extrem: Chronic venous stasis changes. +2 pedal edema. Neuro: alert and oriented x 3. Pertinent Results: CHEST PORT. LINE PLACEMENT [2154-7-16] 1:35 PM: PICC tip is in the SVC. The line is ready for use. Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2154-7-16] 08:12PM 107* 17 1.5* 135 4.5 100 251 15 Brief Hospital Course: Pt was admitted To [Hospital1 18] on [2154-6-30] and was taken to the OR on [2154-7-1]. Operative course uneventful. Opertive course -Pt remained intubated on assist control and in the ICU during the initial post op period. Immediate post op period started on IV vanco and levo as is course for tracheoplasty. Levo d/c'd and will cont on IV vanco x 3 weeks via PICC line-starting [6-30]-end [7-20]//05. Epidural for pain control. Chest tubes to sxn w/ moderate serosang drainage. [Hospital1 ] serial bronch's post operatively for the five days then daily until POD#7 for secretion management. Followed by renal d/t history of ARF w/ previous tracheoplasty. Did have rise in creat post op but responded to volume. POD#4 did begin PSV wean from vent and was extubated on POD#5. Had episode of rapid afib -cardiology consult obatined. Converted to NSR on IV amiodarone and now on po amiodarone for maintenance. Developed Mobitz Type I block on amiodarone. Heart block resolved when amiodarone held x 3 days. Cardiology was reconsulted and recommended amiodarone 200 mg po 3x/week maintenance, weekly EKG's and cardiology follow up upon return home. Pt remains overall deconditioned -amb w/ walker and assist. Cont's to require pulmonary rehab for secretion management assistance. Last bronch on [2154-7-12]. [Month (only) 116] continue to require serial bronch's on PRN basis at rehab. Utilizes cpap Overall plan is for approx 2 weeks of rehab, have follow up visit w/ Dr. [Last Name (STitle) 952] at the end of rehab or in 2 weeks for bronch at [Hospital1 18] to eval status of tracheoplasty then return home to [Location (un) 9012]. Of note, pt developed left hand decub-seen by plastics-silvadene cream and DSD ordered [Hospital1 ]. Medications on Admission: Albuterol and mucomyst nebs q4, combivent prn, flovent", Lasix 40', ASA 81', Lipitor 20', Ambien 10', Ativan 0.5 prn anxiety, Loratadine 10', Tylenol prn pain, Omeprazole 20', Guafenasen, Vit D. Discharge Medications: 1. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscell. Q4-6H (every 4 to 6 hours) as needed. 2. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [Hospital1 ] (2 times a day). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [Hospital1 ] (2 times a day) as needed. 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO 3x per week starting [2154-7-19]. 9. Zolpidem Tartrate 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 10. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal QD () as needed for psoriasis. 11. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [1-6] Puffs Inhalation Q4H (every 4 hours). 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). 13. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q 24H (Every 24 Hours): total of 3 weeks -start date [6-30]- end date [2154-7-20]. 14. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for left hand. 15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 16. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 18. cpap cpap over noc, 02 2LNP during day. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: tracheomalacia - tracheobronchoplasty [2153-11-12] re-do tracheoplasty [2154-7-1] left hand decub. Post op afib, mobitz I Discharge Condition: physically deconditioned w/ need for cont'd pulmonary rehab. cpap over night. O2 2L during day Discharge Instructions: Call Dr. [Last Name (STitle) 952] [Telephone/Fax (1) 170] if you have any questions. Please call if you have fever, chills, shortness of breath, and productive cough. Followup Instructions: Call Dr.[Doctor Last Name ] office for a follow up appointment upon d/c from rehab. Completed by:[2154-7-18]	[ "276.2", "V45.81", "426.13", "272.4", "429.9", "584.9", "519.1", "285.9", "414.00", "427.31", "914.2", "458.29", "V09.0", "491.20", "486", "276.7", "424.0", "E947.8" ]	icd9cm	[ [ [] ] ]	[ "31.79", "00.17", "33.24", "33.22", "38.91", "31.92", "38.93", "96.71", "96.6", "89.64", "34.04", "99.61", "33.48", "96.05" ]	icd9pcs	[ [ [] ] ]	5793, 5872	2054, 3838	382, 419	6047, 6144	1797, 2031	6367, 6486	1438, 1455		4083, 5770		5893, 6026		3864, 4060			6168, 6344									1470, 1778																								255, 344										448, 1010															1032, 1314	1330, 1422
32,627	147,991	46379	Discharge summary	report	Admission Date: [2130-11-8] Discharge Date: [2130-11-19] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern4) 290] Chief Complaint: acute pulmonary edema Major Surgical or Invasive Procedure: Intubation History of Present Illness: Mr. [Known lastname 98553] is a 89yo M w/ a PMH of CAD, CHF (EF 15-20%), HTN, hyperlipidemia, and DM who presents with acute shortness of breath. Pt had gone to his granddaughter's baby shower on [Name (NI) 1017] and afterwards, noted that he was short of breath. His family does not think that he ate any additional salt, but it is unclear. [Name2 (NI) ] presented to [Hospital3 ] on [2130-11-6] where the HPI noted a week of weakness and dyspnea. Initial O2 sats was 80%, BP was 180/92. His CXR was c/w volume overload and he was diagnosed with CHF vs. acute pulmonary edema requiring emergent intubation. He was noted to be a difficult intubation and required LMA mask ventilation before an adequate ETT was able to be placed fiberoptically (7.5 ETT). He was maintained on IMV initially and required a dopamine gtt transiently for hypotension. Initial labs were notable for a normal WBC (7.0), Hct (40.9), and BNP of 1180. EKG showed a paced rhythm. He was given 80mg IV lasix x1 for his edema. On [11-7], CPAP was attempted but pt did not tolerate this due to apnea. CT of the head was performed and was negative for an acute bleed. It did show atrophy c/w age and bilateraly maxillary sinus soft tissue changes, with question of polyps. Pulmonary was consulted and felt his respiratory failure was due to CHF/pulmonary edema. Attempts were made at diuresis with lasix, but he was noted to be in acute renal failure with a Cr of 2.0. His CXR on [11-7] showed some improvement and his sedation was weaned but he went back into pulmonary edema, for reasons that are unclear. His sedation was achieved with versed gtt and boluses of morphine. He was noted to be in afib w/ RVR on [11-8]. He was found to have a troponin leak with a trop I peak of 6.03. An ECHO showed an EF of 15-20%. He was transferred to [Hospital1 18] intubated for cardiac catheterization for NSTEMI. In the cath lab, he was found to have normal coronaries (no occlusion of stents) and he was sent to the CCU for further monitoring. . In reviewing his EKGs from the OSH, on [11-6] he appeared to be v-paced, with intermittent natural conduction which appeared to be LBBB. On [11-8], his EKG showed slow afib with intermitten v-pacing. Native QRS complexes showed TWI in I, II, and aVF and ST depressions in V3. . ROS was unable to be obtained as pt was intubated and sedated. Past Medical History: # CAD: h/o NSTEMIs with multiple stent placements, last in [8-10] to Lcx # s/p pacemaker (? unclear reasons, ? if defibrillator as well) # DM type II # HTN # constipation # hyperlipidemia # s/p back surgery # s/p appendectomy # s/p cholestectomy # s/p hernia repair # Bladder cancer: s/p transurethral resection [2122] and [2123] . Percutaneous coronary interventions: [2117-6-17] - 2VD in R dom system, LAD mild diffuse luminal irreg in prox LAD, 90% stenosis in large high first diagonal branch, LCx had 40% mid portion stenosis, RCA had 80% stenosis proximally, was totally occluded just prior to takeoff of PDA, PDA and posterolateral branch were totally occluded, LV gram showed posterobasal and inferior HK, EF 48%, 1+ MR [2119-3-27] - 2VD in R dom system; LMCA no sig disease, LAD diffusel diseased w/ 50% stenoses in proximal/mid segments, 40% stenosis distally after high D2, large D1 had 90% proximal stenosis and D2 had 50% proximal stenosis, 40% origin stenosis of OM1, RCA had 80% prox stenosis and was occluded before PDA, PASP 44mmHg, LVEDP 15mmHg [2128-10-26] - severe diastolic dysfunction, reduced CI, PCI of LAD/D1 [2129-8-24] - successful PTCA of proximal OM1 w/ overlapping DES, PTCA of jailed ostial diagonal artery . Pacemaker/ICD placed: date unknown Social History: Pt is married, but lives alone. His wife is currently living in a [Name (NI) 1501]. Has one daughter who is very involved in his care. Past h/o tobacco use but none currently. No EtOH use. Family History: Non- contributory Physical Exam: VS: T 99.2, BP 100/46, HR 57, RR 16, O2 97% on AC 550x12, FiO2 60%, PEEP 5 Gen: Elderly male, sedated and intubated. HEENT: NCAT. Sclera anicteric. Pupils pinpoint, unable to assess reactivity. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. ETT in place. Neck: Supple, but no appreciable JVD. Chest: Pacer in L chest, laterally. No tenderness, warmth or erythema. CV: PMI located in 5th intercostal space, midclavicular line. Irreg, irreg. Normal S1, S2. No murmurs appreciated. Chest: CTA anteriorly and at bases. No crackles, no wheezes. Abd: Thin, soft, NTND, no HSM or tenderness. No abdominial bruits. + BS throughout. Ext: No c/c/e. No femoral bruits. R groin w/o hematoma. Dsg c/d/i. Feet are cool bilaterally. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ PT Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ PT Pertinent Results: CARDIAC CATH performed on [2130-11-8]: prelim: LMCA normal, LAD patent stent, 60% diag, LCx patent stent, RCA known occuluded. . HEMODYNAMICS [2130-11-8]: Ao 100/37, mean 62 RA mean 4, A wave 7, V wave 9 RV 31/2, end 7 PCW mean 4, A wave 13, V wave 11 PA 40/16, mean 23 . ECHO [2130-11-9]: Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed (LVEF= 20-30 %) secondary to severe hypokinesis-to-near akinesis of the inferior septum, inferior free wall, and posterior wall. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular chamber size is normal. Right ventricular systolic function appears depressed. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . Compared with the findings of the prior study (images reviewed) of [2129-8-25], the mitral regurgitation is increased. . CT abdomen/pelvis: IMPRESSION: 1. No evidence of retroperitoneal bleed. 2. Stable lesion in the dome of the liver likely represents simple cyst or hemangioma. 3. Numerous large simple-appearing renal cysts bilaterally. 4. Sigmoid diverticulosis without evidence of diverticulitis. . Renal US: IMPRESSION: No evidence of renal artery stenosis. Normal flow to kidneys bilaterally. No hydronephrosis. . Chest CT: IMPRESSION: 1. No bronchial obstruction or bronchiectasis. Severe bilateral consolidation and bronchopneumonia, possibly hemorrhagic. Minimal reactive central adenopathy. 2. Unhcharacterized liver lesion should be evaluated with ultrasound. 3. Severe atherosclerosis including coronary arteries. Possible calcific aortic stenosis. 4. Anasarca and small nonhemorrhagic bilateral pleural effusions. 5. Marked left atrial enlargement. . Labs: Brief Hospital Course: 89yo M w/ CAD s/p multiple stents, pacemaker, CHF w/ EF 15%-20%, [Hospital 23051] transferred from OSH after being intubated for CHF exacerbation in setting of NSTEMI, subsequently developed MSSA bacteremia and PNA and acute on chronic renal failure. After considering the patient's overall prognosis, his family decided to refocus the goals of his care on comfort only. Non-comfort therapies, including ventilatory support, were withdrawn, and the patient passed away shortly thereafter. . # ID: Patient was initially admitted with a CHF exacerbation. He was then found to have MSSA Bacteremia and MSSA PNA. His antibiotics were changed to Nafcillin on [11-13] after being initially started on Vancomycin and Zosyn for empiric coverage. Unfortunately, he failed to improve and was unable to be weaned from the ventilator despite multiple attempts. Once ventilatory support was withdrawn the patient expired within several hours. . # Respiratory Failure/PNA: As above. The patient was also noted to developed what appeared to be hemorrhaging ETT secretions. The pulmonary team was consulted on [11-15] for possible bronchoscopy, but this was deferred. Nafcillin was continued until the patient was transitioned to comfort measures. . # Cardiac: A cardiad cath showing left main normal, LAD patent stent, 60% diag lesion, Lcx patent stent, RCA known occluded. Many of the patient's home cardiac medications were held in the setting of hypotension, renal failure and concern for possible internal bleeding. . # Acute on Chronic Renal Failure: The patient's baseline creatinine is known to be 1.4-1.5. At the time of admission, following an IV dye load in the cath lab, it quickly rose to IV contrast dye load in cath 2.3 with a BUN around 113. The precise etiology of this remained unclear; ddx included nephrotoxins, ATN; AIN was thought to be less likely. Septic renal infarct, cystic kidney dz, and renal artery stenosis were also considered. The patient was followed by the renal team. Dialysis was deferred as the patient continued to have good urine outpt and resond to diuresis. He was then transitioned to comfort-focused care. . # DM: The patient was briefly managed on an insulin gtt for persistently elevated blood sugars; this was transitioned to sliding scale and eventually d/c'd altogether. . # Hypernatremia: The patient was intially hypernatremic with a peak of 149. He was started on free water flushes and his sodium slowly normalized. Medications on Admission: HOME MEDS: prilosec 20mg PO daily glyburide 5mg PO daily lasix 40mg PO daily coreg 6.25mg PO BID plavix 75mg PO daily imdur 60mg PO daily accupril 40mg PO daily aspirin 325mg PO daily lipitor 40mg PO daily aldactone 20/25mg PO daily tylenol prn Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Primary: PNA c/b respiratory failure renal failure Secondary: # CAD # s/p pacemaker # DM type II # HTN # hyperlipidemia # Bladder cancer: s/p transurethral resection [2122] and [2123] Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "428.0", "428.22", "038.11", "410.71", "250.00", "995.92", "584.9", "518.81", "V45.01", "403.90", "482.41", "272.0", "285.9", "585.9", "276.0", "427.31" ]	icd9cm	[ [ [] ] ]	[ "37.23", "38.93", "96.6", "96.72", "96.04", "38.91", "88.56" ]	icd9pcs	[ [ [] ] ]	10383, 10392	7588, 10056	292, 304	10628, 10637	5267, 7565	10693, 10839	4280, 4299		10351, 10360		10413, 10607		10082, 10328			10661, 10670									4314, 5248																								231, 254										332, 2726															2748, 4054	4070, 4264
55,643	168,460	39982	Discharge summary	report	Admission Date: [2126-11-4] Discharge Date: [2126-11-13] Date of Birth: [2047-12-15] Sex: F Service: CARDIOTHORACIC Allergies: Demerol Attending:[First Name3 (LF) 1505] Chief Complaint: headache and dizziness s/p fall Major Surgical or Invasive Procedure: [2126-11-8] Aortic valve replacement with a 21 mm Magna ease tissue valve. [2126-11-4] Cardiac Catheterization History of Present Illness: 78 year old female with history of severe aortic stenosis who woke up this morning, felt ill, got out of bed and felt nauseated. She walked several steps, fell forward and broke her fall with her arms. She did not lose consciousness. She did not hit her head. She crawled to the phone an called an ambulance and was taken to the [Hospital1 1474] ED, where she was noted to have chest pain. In addition, she was vomitting, Cold (96 rectally), diaphoretic and hypotensive to 74/56. Per her sister, the patient has been non-compliant with her medications due to high cost. She accidentally took double her dose of HCTZ for several weeks. In the [Hospital1 1474] ED, the patient was given intravenous fluids, zofran, morphine 1mg, ASA 325mg, and was started on a heparin drip with a Bolus of 5750U at 1320 and a drp at 1300U/hr. Her chest pain resolved after 1mg of morphine. She had a troponin of 0.22, and ST depressions in the lateral leads. She was transferred to [Hospital1 18] for cardiac catheterization. Past Medical History: Aortic Stenosis CVA in [5-6] hypothyroidism hypertension s/p appendectomy s/p hemorrhoidectomy s/p hysterectomy s/p cataract surgery Social History: Lives alone. Good family support -Tobacco history: distant past (over 50 years ago) but she did live with a smoker until 10 years ago -ETOH: denies -Illicit drugs: denies Family History: Brother had MI in his 50s. Physical Exam: VS: T=97.6 BP=119/62 HR=62 RR=18 O2 sat=93 RA GENERAL: Obese 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. Mucous membranes dry. No xanthalesma. NECK: Supple with no JVD. Neck is large. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2 with a loud midsystolic crescendo decrescendo murmur radiating to the carotids. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ Left: Carotid 2+ Femoral 2+ DP 2+ Pertinent Results: [2126-11-12] 04:13AM BLOOD WBC-6.6 RBC-3.16* Hgb-10.0* Hct-29.8* MCV-94 MCH-31.6 MCHC-33.5 RDW-15.7* Plt Ct-72* [2126-11-4] 04:45PM BLOOD WBC-6.1 RBC-3.20* Hgb-10.0* Hct-30.4* MCV-95 MCH-31.1 MCHC-32.7 RDW-14.2 Plt Ct-133* [2126-11-12] 04:13AM BLOOD Plt Ct-72* [2126-11-11] 01:40AM BLOOD PT-13.0 PTT-28.2 INR(PT)-1.1 [2126-11-9] 04:15AM BLOOD Plt Ct-50* [2126-11-4] 04:45PM BLOOD Plt Ct-133* [2126-11-4] 04:45PM BLOOD PT-12.9 PTT-45.0* INR(PT)-1.1 [2126-11-4] 04:45PM BLOOD Ret Aut-1.8 [2126-11-13] 03:57AM BLOOD UreaN-29* Creat-1.2* Na-143 K-3.4 Cl-107 [2126-11-12] 04:13AM BLOOD Glucose-101* UreaN-23* Creat-1.1 Na-139 K-3.7 Cl-106 HCO3-26 AnGap-11 [2126-11-10] 04:08AM BLOOD Glucose-104* UreaN-16 Creat-1.3* Na-136 K-4.0 Cl-107 HCO3-22 AnGap-11 [2126-11-4] 04:45PM BLOOD Glucose-146* UreaN-20 Creat-0.9 Na-139 K-3.7 Cl-108 HCO3-26 AnGap-9 [2126-11-10] 05:25PM BLOOD CK(CPK)-168 [2126-11-4] 04:45PM BLOOD ALT-31 AST-43* AlkPhos-69 Amylase-20 TotBili-0.3 [2126-11-4] 04:45PM BLOOD %HbA1c-5.7 eAG-117 [2126-11-11] 12:00AM BLOOD HEPARIN DEPENDENT ANTIBODIES- Brief Hospital Course: Transfered for cardiac evaluation and underwent cardiac catheterization which revealed no significant coronary artery disease. She was referred for surgical evaluation due to aortic stenosis. She underwent preoperative workup and was brought to the operating [2126-11-8] for aortic valve replacement. See operative report for further details. Vancomycin was given for perioperative antibiotics and she was transferred to the intensive care unit for post operative management. She remained intubated due to hemodynamics and oxygenation. On post operative day one she was weaned but required increased PEEP and was gently diuresed due to volume overload and remained intubated. On postoperative day two she was weaned and extubated and continued with lasix for diuresis. Additionally she had thrombocytopenia post operative day one, lines were changed to heparin free, HITT was sent which was negative, and platelet count was monitored and increased to > 70 on post operative day 4, epicardial wires were then removed. She was started on betablockers that were titrated up and ACE inhibitor was started for blood pressure management. She continued to progress and was screened for rehab - she was ready for discharge post operative day 5 to [Location (un) ] of [Location (un) 701]. Her aggrenox was not resumed due to platelet count Medications on Admission: aggrenox 25-200 mg [Hospital1 ] HCTZ 25 mg daily levothyroixine 75 mcg daily metoprolol succinate 25 mg daily simvastatin 80 mg daily Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain/fever: if not taking percocet . 7. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 8. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days. 10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Location (un) ] at [Location (un) 701] Discharge Diagnosis: Aortic Stenosis s/p AVR hypothyroidism hypertension Discharge Condition: Alert and oriented x3 nonfocal Ambulating with 1 assist Incisional pain managed with Percocet Incisions: Sternal - healing well, no drainage, small amount erythema Edema +1 bilateral lower extremities Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [Last Name (STitle) ] [Telephone/Fax (1) 170] Date/Time:[2126-12-5] 1:00 Cardiologist: Dr [Last Name (STitle) ] [11-19] at 8:15am Please call to schedule appointments with your Primary Care Dr [Last Name (STitle) 6700] in [4-1] weeks [Telephone/Fax (1) 6699] 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:[2126-11-13]	[ "041.4", "780.2", "244.9", "458.29", "276.69", "272.4", "V12.54", "401.9", "599.0", "416.8", "287.5", "424.1" ]	icd9cm	[ [ [] ] ]	[ "35.21", "39.61", "88.56", "37.23" ]	icd9pcs	[ [ [] ] ]	6556, 6630	3981, 5334	309, 430	6726, 6929	2835, 3958	7852, 8401	1852, 1880		5522, 6533		6651, 6705		5360, 5499			6953, 7829									1895, 2816																								237, 271										458, 1487															1509, 1648	1664, 1836
81,983	185,243	43330	Discharge summary	report	Admission Date: [2147-9-17] Discharge Date: [2147-9-21] Date of Birth: [2084-1-6] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 78] Chief Complaint: CC:"right sided headache and right sided neck pain" Major Surgical or Invasive Procedure: [9-18]: Cerebral angio History of Present Illness: HPI:This is a 63 year old male with complaints of right sided headache and right neck pain that radiates to the right shoulder. This was a level 10 on a [1-29] pain scale this morning which brought him into the hospital. He states that he has been having similar episodes for the last 3 weeks, once a week. He has had 2 episodes of nausea with emesis over the past week. He ambulates with a cane at baseline for the past 3 months for right leg weakness of unknown origin. He denies nausea or vomiting, numbness or tingling sensation, visual disturbance or hearing deficit. Past Medical History: HTN, DM, arthritis, LBP, bilateral cataract surgery. Social History: Lives independently. Family History: Non-contributory. Physical Exam: ROS:as mentioned above PHYSICAL EXAM: O: T: 97.7 BP: 151/88 HR: 85 R:18 O2Sats:98% Gen: WD/WN, comfortable, NAD. HEENT: Pupils:3-2.5mm EOMsintact Neck:right head and neck pain on left increased with ROM Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect, patient appears slightly frustrated during exam. Orientation: Oriented to person, place, and date. Language: Pt unable to name "watch" or "ring". Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3-2.5 to mm bilaterally. Visual fields cut bilaterally -appear impaired bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [5-24] throughout. No pronator drift Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally Coordination: slow to complete finger-nose-finger, rapid alternating movements intact. PHYSICAL EXAM UPON DISCHARGE: awake alert and oriented x3 PERRL, EOMI face symmetric, tongue midline no pronator drift MAE's with 5/5 strengths sensation intact to light touch following all commands Pertinent Results: [9-17]: CTA head and neck: No evidence of dissection. Approximately 4-mm left anterior cerebral artery A2 segment aneurysm. [9-17]: CXR: No acute cardiopulmonary abnormality. [9-19]: MRI C-spine: IMPRESSION: Suboptimal study due to motion artifact. No evidence of cord compression or significant spinal canal narrowing. There is, however, a small posterior disc protrusion at C3-4 and ventral remodeling of the cord at this level. [9-20] U/S Right UE: IMPRESSION: No pseudoaneurysm and no hematoma seen in the right axilla. Brief Hospital Course: On [9-17], the patient was admitted to ICU with q 1 hour neuro checks. His goal BP < 140mmHg. He did not require infusion of vasoactive drugs for this. He was made NPO for possible angio on Monday [2147-9-18]. He has remained neurologically intact. Cardiac Enzymes x3 were performed, which ruled out MI. [9-18]: After remaining neurologically intact overnight, he was taken for a diagnostic cerebral angiogram which confirmed a left ACA aneurysm. No other vascular malformations were noted. He was kept on bedrest for the remainder of the evening. On [9-19]: An MRI c-spine was obtained to work up the patient's complaint of right neck and shoulder pain. Neurology was also consulted for help working up the patient's complaint of continued headaches.PO diabetic medications were restarted. [9-20]: An Ultrasound of the right axilla was ordered after physical exam revealed a tender right axilla with limited ROM in the right arm secondary to pain. The patient had an axillary arterial line that was recently placed and removed. There is concern for hematoma formation, local nerve damage vs. pseudoaneurysm formation. The US revealed no pseudoaneurysm. [9-21]: Pt is without neurological complaint. Denies pain, N/V. His spirits are up and he is looking forward to going home. He was seen by PT who cleared him for discharge with a rolling [Month/Day (2) ]. He was discharge home with follow up in 6 months. Medications on Admission: Glucophage, glibizide, actos, atenolol, reglan. Discharge Medications: 1. Acetaminophen 325 mg Tablet [Month/Day (2) ]: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 2. Docusate Sodium 100 mg Capsule [Month/Day (2) ]: One (1) Capsule PO BID (2 times a day). 3. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet [Month/Day (2) ]: [1-21] Tablets PO Q4H (every 4 hours) as needed for h/a. Disp:30 Tablet(s) Refills:0 4. Metformin 500 mg Tablet [Month/Day (2) ]: One (1) Tablet PO BID (2 times a day). 5. Glipizide 5 mg Tablet [Month/Day (2) ]: 0.5 Tablet PO DAILY (Daily). 6. Pioglitazone 15 mg Tablet [Month/Day (2) ]: Two (2) Tablet PO DAILY (Daily). 7. Rolling [First Name5 (NamePattern1) 4886] [Last Name (NamePattern1) ]: One (1) x1: DX: cervical tension. Disp:1 1 Refills:0 Discharge Disposition: Home With Service Facility: [First Name9 (NamePattern2) 269] [Location (un) 86] Discharge Diagnosis: Cerebral aneurysm. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Headache with Incidental Aneurysm finding confirmed with Diagnostic Cerebral Angiogram ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. ?????? You may wear a soft collar for comfort if your headache returns. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. You may exercise as tolerated. ?????? You may shower Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [First Name (STitle) ] to be seen in 6 months. You will need an MRI/MRA of your brain before this appointment. ?????? You will also follow up with the neurologist. Please call ([Telephone/Fax (1) 35413] to obtain the date and time of this appointment. Completed by:[2147-9-21]	[ "437.3", "250.00", "307.81", "724.2", "401.9" ]	icd9cm	[ [ [] ] ]	[ "38.91", "88.41" ]	icd9pcs	[ [ [] ] ]	5671, 5761	3333, 4778	369, 398	5823, 5823	2761, 3310	6425, 6840	1138, 1157		4878, 5648		5782, 5802		4804, 4853			5974, 6402									1211, 1428																								277, 331						2571, 2742				426, 1007	1766, 2541										5838, 5950				1029, 1084	1100, 1122
44,038	156,006	42909	Discharge summary	report	Admission Date: [2120-12-23] Discharge Date: [2120-12-25] Date of Birth: [2060-7-6] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2901] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2120-12-23] - Cardiac Catheterization with single drug-eluting stent the right coronary artery (Promus stent) History of Present Illness: The patient is a 60M with prior history of MI s/p stent who was in his normal state of health until this morning when developed sudden onset substernal chest pain at rest. He was watching television when developed [10-28] SSCP that radiated to both arms and was associated with shortness of breath and diaphoresis. He reports this was almost identical to prior MI. He took SLNG x2 with resolution of CP to [3-22] out of 10. He then took 2 more doses of SLNG without resolution of CP. He called EMS. Initial EKG by EMS per report showed ST elevations in II/III. He was given aspirin 325mg and SLNG with some improvement in chest pain. En route, inferior ST elevations resolved. Of note, the patient is a poor historian whose first language is Haitian Creole, so an interpreter was used to obtain a limited history and the history was discussed with his daughter as well. . In the ED, repeat EKG showed return of ST elevations in II/III. He was given heparin and 8mg morphine with improvement of pain (he was not given plavix). He was taken to the catheterization lab. He was found to have LAD: 30% mid; LCX 80% proxima; 70% mid complex; 80% inferior branch of OM1. RCA: 95% mid thrombotic, patent stent in posterolateral. DES was placed in RCA with 2.75 x 23 Promus with good result. He received bilvalirudin, nicardipine, nitroglycerin, plavix 600mg. . He reports that he was in his usual state of health until this episode. He has been experiencing lower back pain since [Month (only) 216] which occurred suddenly without trauma. He has been treating with tylenol and ibuprofen, without improvement. He also has been experiencing left sided leg pain for 2 years which has not changed. He denies DOE but his daughter reports [Name2 (NI) 15430] he has been dyspneic with minimal movement for months. He also reports that he has been having chest pain intermittently for months which has been relieved by nitro. He also reports that he has left sided leg pain, which may be worse with ambulation. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or pre-syncope. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - CABG: none - PERCUTANEOUS CORONARY INTERVENTIONS: [2112] PDA intervention - PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - pain in left leg ?claudication - pain in lower back - GERD - remainder of pmhx is not known to the patient Social History: - Tobacco history: the patient has been smoking cigarettes since [2072]. He has been smoking at least 1ppd but has been cutting back recently to 1 pack every 3 days. 47 pack years - ETOH: max 1 glass of wine per day but last drink 5 months ago - Illicit drugs: denies Recently laid off from working as a valet Lives alone. Independent in ADLs Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - Mother: htn - Father: hernia - Siblings: unknown Physical Exam: PHYSICAL EXAMINATION (on admission): GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. CARDIAC: Distant heart sounds. PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, initially minimal R crackles at bases but cleared with deep inspiration, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. R femoral artery with mild bleeding with angioseal intact. No bruising. No bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . ON DISCHARGE: Unchanged from admission Pertinent Results: [2120-12-23] 07:35AM BLOOD WBC-PND RBC-5.27 Hgb-13.8* Hct-42.4 MCV-81* MCH-26.2* MCHC-32.5 RDW-13.8 Plt Ct-PND [2120-12-23] 07:35AM BLOOD PT-11.5 PTT-29.9 INR(PT)-1.1 [2120-12-23] 07:35AM BLOOD Glucose-114* UreaN-19 Creat-0.9 Na-142 K-4.0 Cl-105 HCO3-25 AnGap-16 [2120-12-23] 07:35AM BLOOD cTropnT-<0.01 [2120-12-23] 07:35AM BLOOD Calcium-9.7 Phos-3.7 Mg-1.9 DATA: - ECG: ST elevations in II, III aVF. Depressions in aVL, V4-V6, resolving in post-cath. - LHC [2120-12-23] He was found to have LAD: 30% mid. LCX 80% proximal; 70% mid complex; 80% inferior branch of OM1. RCA: 95% mid thrombotic, patent stent in posterolateral. DES was placed in RCA with 2.75 x 23 Promus with good result. He received bilvalirudin, nicardipine, nitroglycerin, plavix 600mg. - TTE ([2120-12-24]) - The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with basal inferior hypokinesis. The remaining segments contract normally (LVEF = 55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve 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 regional left ventricular systolic dysfunction, c/w CAD. No clinically-significant valvular disease. Discharge labs: [2120-12-25] 05:51AM BLOOD WBC-8.2 RBC-5.14 Hgb-13.4* Hct-40.5 MCV-79* MCH-26.0* MCHC-33.0 RDW-13.6 Plt Ct-158 [2120-12-25] 05:51AM BLOOD Plt Ct-158 [2120-12-25] 05:51AM BLOOD Glucose-98 UreaN-14 Creat-0.8 Na-140 K-4.1 Cl-105 HCO3-28 AnGap-11 [2120-12-24] 05:02AM BLOOD CK(CPK)-113 [2120-12-25] 05:51AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.2 Cholest-PND [2120-12-25] 05:51AM BLOOD Triglyc-PND HDL-PND Brief Hospital Course: 60M Haitian Creole speaking only who presents with a PMH history of HTN, HLD and coronary artery disease who presented with chest pain and was transferred to the CCU following an ST-segment elevation with coronary angioplasty resulting in single Promus stenting of the right coronary artery. . # CORONARY ARTERY DISEASE - The patient has a past medical history of CAD and has been stented in the PDA in the past. He is s/p stenting of his RCA on [2120-12-23] with a single drug-eluting Promus stent. He received Bilvalirudin therapy post-cardiac cath which was completed without issue. He also has diffuse disease in his LCx, which will require ETT and evaluation in the future. Troponin peaked at 0.35. His TTE after cardiac cath with PCI showed a preserved EF of 55% and some mild LV basal inferior hypokinesis. We started metoprolol during this admission, he was previously prescribed atenolol which he had not been taking. He was also started on lisinopril and high-dose atorvastatin. At discharge, he will continue Plavix for 1 year for his DES. . # RHYTHM - The patient has no known heart dysrrhythmias, but the patient is s/p STEMI and was monitored for post-MI arrhythmias. No concerning changes were found on tele or on EKGs. . # HLD - Reportedly he has a past medical history of hyperlipidemia. We obtained a fasting lipid panel which was pending at time of discharge. At discharge, he will continue atorvastatin 80 mg PO daily. . # GERD - We continued Omeprazole. . # HTN - His home regimen includes Lisinopril 2.5mg daily, Atenolol 25 mg qday (not taking the latter). Given STEMI, he was changed to metoprolol XL 75mg and lisinopril 5 mg for antihypertensives. . TRANSITION OF CARE ISSUES: 1. CODE: FULL CODE 2. COMM: [Name (NI) 14552], daughter, [Telephone/Fax (1) 92612] 3. TRANSITION OF CARE: - Patient will require ETT and follow up with cardiologist. - He will require TOBACCO CESSATION counseling - Plavix x1 year 4. PENDING STUDIES: - LIPID PANEL Medications on Admission: HOME MEDICATIONS: - atenolol 25mg qd (not picked up since [Month (only) 216]) - Plavix 75mg qday - Lisinopril 2.5mg qday - Omeprazole 20mg qday - SL NTG 0.4mg PRN chest pain Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily): Please discuss tapering this . Disp:30 Patch 24 hr(s) Refills:0 7. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:90 Tablet Extended Release 24 hr(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: primary diagnosis: coronary artery disease, hypertension, hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname ], You were admitted to the Cardiac Intensive Care Unit because you had a heart attack. You received a drug eluting stent in your artery. You still have disease in one of your other arteries, which will require further diagnostic assessment with a "stress test" in the future. You should discuss this test with your new cardiologist. You can prevent this from happening again by taking all of your medications and by making sure that you quit smoking. You also need to eat a good diet, avoiding fats. Please be sure to take all of your medications, but Plavix is especially important to take for one year at least. Do not stop taking this medication unless you are told to do so by a physician. YOU MUST QUIT SMOKING. IT WILL KILL YOU. Please be sure to note the following changes to your medications: - START Atorvastatin - START Metoprolol - STOP Atenolol - INCREASE Lisinopril from 2.5mg to 5mg daily - START Aspirin - CONTINUE Plavix - CONTINUE omeprazole - START Nicotine Patches, please discuss tapering with your physician. Please be sure to follow up with your physicians. Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) ] S Location: [Hospital6 ]-FAMILY MEDICINE Address: [Location (un) 11452] 2ND FL, [Location (un) ],[Numeric Identifier 5138] Phone: [Telephone/Fax (1) 65318] Appointment: MONDAY [12-30] AT 11AM Department: CARDIAC SERVICES When: WEDNESDAY [2121-1-22] at 9:00 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909]	[ "305.1", "412", "440.21", "724.2", "530.81", "410.21", "414.01" ]	icd9cm	[ [ [] ] ]	[ "00.40", "37.22", "00.66", "36.07", "88.56", "00.45" ]	icd9pcs	[ [ [] ] ]	10018, 10024	6946, 8930	316, 432	10141, 10141	4915, 6485	11429, 12123	3702, 3872		9158, 9995		10045, 10045		8956, 8956			10292, 11406		6502, 6923							3887, 4856				3077, 3179	8974, 9135											4870, 4896								266, 278										460, 2947								10064, 10120			10156, 10268	3210, 3320			2991, 3057	3336, 3686
45,419	103,293	52291	Discharge summary	report	Admission Date: [2174-3-18] Discharge Date: [2174-4-14] Date of Birth: [2095-12-29] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3984] Chief Complaint: 66% atypical white blood cells and low platelets on a routine CBC. Major Surgical or Invasive Procedure: Intubation History of Present Illness: History of Present Illness: The pt is a 78 yo M with a h/o CAD, HTN, HL, DM who presents from his PCP's office after routine CBC showed 66% atypical white blood cells and low platelets on a routine CBC. He initially sought care from his PCP after he had noticed that he had noticed increased bleeding from the site of a removed childhood skin tumor which had been severely pruritic, causing him to scratch it with a sharp back-scratcher repeatedly. The PCP felt the patient had an infected cyst and started abx. His PCP drew [Name Initial (PRE) ] CBC which showed 66% atypical white cells and thrombocytopenia with a normal white cell count and hematocrit. He then ordered immunophenotyping which is pending, and sent the patient to the ED. On review of systems, the patient also notes more malaise and dyspnea on exertion over the last month, as well as intermittently blood streaked stools and melena. In the ED, the patient was noted to have no evidence of bleeding but labs concerning for DIC and tumor lysis. He was seen by the heme-onc consult fellow. He was given 2 amps of bicarb with D5W at 100 cc/hr. He was given 10u of cryoprecpitate and transfused platelets. He also received 50 mg PO of all-trans retinoic acid. Review of Systems: (+) recent chills, headaches, (-) Review of Systems: GEN: No night sweats, recent weight loss or gain. HEENT: No headache, sinus tenderness, rhinorrhea or congestion. CV: No chest pain or tightness, palpitations. PULM: No cough, or wheezing. GI: No nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel habits. GUI: No dysuria or change in bladder habits. MSK: No arthritis, arthralgias, or myalgias. DERM: No rashes or skin breakdown. NEURO: No numbness/tingling in extremities. PSYCH: No feelings of depression or anxiety. All other review of systems negative. Past Medical History: Past Oncologic History: Received radiation as child to back for "tumors". . Other Past Medical History: CAD - stable angina Gout - no recent flares HTN PUD - last EGD [2169] Type II DM - A1c 6.2% on metformin Social History: He lives with his partner, [Name (NI) ], who he has been with for over 50yrs and married to for 6 yrs. He has one brother who his is not in contact with and no children. He has had several prior employments, including journalism, dance, stage management, and travel reporter. He also worked as a silver [Doctor Last Name ] when he was exposed to sulfer products. He has travelled extensively. Last HIV negative 1 year ago, Hepatitis negative in the distant past. He has a distant history of smoking for 1 year. He has a history of 'heavy' drinking with scotch, but now drinks only wine with dinner per his report. Smokes occasional marijuana, and distant history of experimenting with other drugs. Family History: Father died of MI at 51. Mother of throat cancer in early 80s after long smoking and alcohol history. His brother is apparently healthy. Physical Exam: On Admission: VS: T: 100.6 F, BP 130/78, HR 96, RR 20, O2sat 100% on RA GEN: AOx3, NAD HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. No cervical, supraclavicular, or axillary LAD Cards: RRR. S1/S2 normal. no murmurs/gallops/rubs. Pulm: No dullness to percussion, CTAB no crackles or wheezes Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [Doctor Last Name 515] sign Extremities: wwp, no edema. DPs, PTs 2+. Skin: excoriations in R axilla. scab centrally located on central thoracic back with mild surrounding erythema but no purulent drainage or warmth though somewhat tender Neuro: CNs II-XII intact. 5/5 strength globally. sensation intact to LT, gait WNL. Pertinent Results: Admission labs: [2174-3-17] 04:55PM BLOOD WBC-5.3 RBC-3.96* Hgb-11.9* Hct-32.8* MCV-83 MCH-30.2 MCHC-36.4* RDW-14.9 Plt Ct-22# [2174-3-18] 10:00AM BLOOD PT-16.1 PTT-22.0 INR(PT)-1.4* [2174-3-17] 04:55PM BLOOD UreaN-22* Creat-1.2 Na-137 K-4.5 Cl-99 HCO3-28 AnGap-15 [2174-3-17] 04:55PM BLOOD Glucose-143* [2174-3-18] 05:32PM BLOOD ALT-24 AST-33 LD(LDH)-483* AlkPhos-68 TotBili-1.0 Brief Hospital Course: 78 yo male with distant history of stable angina, new diagnosis of acute promyelocytic leukemia, transferred to the ICU with tachycardia after ATRA treatment on the hematology malignancy floor, with DIC, pulmonary edema, and delirium. . # APML: He was diagnosed with APML with 56% blasts on differential [2174-3-18]. He was treated with ATRA and subsequently suffered from ATRA syndrome with an acute elevation in his WBC to >50 K. He had significant pulmonary leak. He was treated with ATRA throughout and received Idarubicin which had to be stopped secondary to elevated bilirubin. His blasts and WBC subsequently decreased, and on smear [2174-4-4] his myelocytes showed differentiation with improving status of his leukemia. ATRA was continued throughout his hospitalization. As a consequence of treatment, his course was complicated by tumor lysis syndrome with his uric acid peaking above 10, with a change an increase in creatinine to 2.5 initially and subsequently higher as described below. He was treated with allopurinol initially, and required a 1x dose of Rasburicase which led to the resolution of his TLS. He was maintained on his allopurinol for continued treatment. . # Respiratory Failure: Likely multifactorial in the setting of pulmonary leak from ATRA and likely alveolar hemorrhage. His fluid balance reached a peak of 27L positive secondary to his blood product requirement. He initially required a PEEP of 22 with FiO2 of 100%. Over the course of 10 days he was able to be weaned down with the assistance of CVVH for fluid overload to pressure support of [5-19]. His mental status was the largest obstacle to extubation and he was taken for tracheotomy tube placement by Thoracic Surgery on [2174-4-8]. He tolerated the procedure well, and was able to be transitioned to trach collar starting on [2174-4-10] for periods of time. . # DIC: Due to his APML, he developed DIC evidenced by active bleeding from his ET tube, his OG tube, his stool and urine. He had acute drops in fibrinogen, increase in LDH and increase in bilirubin. He was supported through this with massive transfustions requiring 18 units of PRBCs, 35 units of platelets, 5 units of FFP, and 24 units of cryoprecipitate. He was intubated due hypoxia and increased work of breathing on [2174-3-26]. His CXR after intubation showed a fluffy infiltrate suggestive of either ARDS or hemorrhage (likely both). Due to his subdural hematomas, he was transfused to goals of Hct>30, plts > 100, fibrinogen > 175, and INR <1.6. Once the DIC resolved, his goals changed to Hct>25, plts > 20, fibrinogen > 100, and INR <1.6. . # Toxic Metabolic Encephalopathy: He started experiencing a decline in mental status 2 days prior to intubation with severe asterixis and confusion. He had a number of potential causes such as medications, central focus with his SDH, and hypertension to 180 making PRES a less likely, but possible concern. Also, his uremia given his acute renal failure. He required several doses of Haldol and intermittent restraints for safety prior to intubation, when he was put on midazolam and Fentanyl drips. 5 days after intubation his was sedation was discontinued and he remained obtunded. He was treated with dialysis for a uremia over 200. His mental status was the barrier to extubation as his vent setting were minimal at the point of weaning sedation. He was non responsive after 4 days off of sedation. A family meeting was held with his husband [Name (NI) ], and the decision was made to take him to trach, with the goal of trying to improve his mental status with dialysis. # Acute renal failure: His creatinine sharply rose from 1.2 on admission to a peak of 4.9. This was thought to be in the setting of Tumor Lysis Syndrome (TLS) and abdominal compartment syndrome. Also complicated by ATN in the setting of low blood volume and possible microthrombi during DIC. He was treated allopurinol and Rasburicase for TLS with good resolution as well as with CVVH initially (1 day) for fluid removal. His urine output responded. Shortly after he began autodiuresing He was initiated on dialysis for AMS as described above and a BUN of greater than 200. He was treated with dialysis with a fall in BUN to 113, however, he had a fever to 100.6 and cultures came back positive for GPC in chains from dialysis catheter [2174-4-9]. . # Abdominal Compartment Syndrome: In the setting of acute volume overload from large volume transfusions given DIC as above. He was ~25L positive for LOS fluid balance. He developed elevated bladder pressures and decreased urine output. Surgery was consulted and felt that as long as he was making urine there was no need for surgical intervention (as well as given his critical illness, it was not indicated). He was started on CVVH as above and had 3L removed. His kidneys responded and began making 100-200cc/hr of urine. His CVVH was stopped and he was allowed to diurese on his own with support of lasix and metolazone as needed. . # Atrial Fibrillation / Flutter: He developed tachycardia to the 140s with initial EKG most consistent with Afib, and later EKG more consistent with Aflutter vs AVNRT. His HR did not respond to Diltiazem drip or multiple subsequent IV boluses of Diltiazem and Metoprolol. Cardiology suggested Verapamil, followed by Amiodarone. He was loaded with Amiodarone drip and bolus of 150 mg x2. He was cardioverted on [2174-3-22] and continued on Amiodarone. He got an extra 150mg of amiodarone on [3-25] with minimal effect on tachycardia. He converted to NSR, and reverted back to atrial fibrillation. In the setting of controlling his blood pressure with IV medications he received multiple doses of metoprolol and labetalol, and he converted to NSR. However, [4-1] he converted back to rapid a-fib with RVR and required uptitration of his B-blockade and a diltiazem drip which was eventually converted back to PO. . # Bilateral Subdural Hematomas: Unclear time course. Neurosurgery followed along and he had serial scans. His hematomas had interval increased in the setting of the DIC; however, not thought to be clinically significant. Neurosurgery preferred medical management with antiepileptics and reversal of his coagulopathy. . # Right basal ganglia infarct: On repeat scan of his head to evaluate interval change of his subdural hematomas on [2174-4-4], a new right sided basal ganglia infarct was noted. Neurosurgery followed, and neurology was consulted. They felt that medical management and blood pressure control were the best means of treatment. . # Positive Blood Cultures: Blood cultures were positive in [2-16] bottles from his PICC line on [2174-3-22]. The aerobic culture was speciated as Staph aureus. No peripheral culture was obtained on that date. He was started on Vancomycin / Meropenem on [2174-3-22] after spiking a fever to 102.5. This was changed to Vancomycin / Cefepime the next day. Given the concern for translocation of gut bacteria with his compromised immune system, he was switched to Vancomycin / Zosyn on [2174-3-24] for better coverage of gut pathogens. Micafungin was added to cover for fungal pathogens. He had multiple sets of negative surveillance cultures, and his antibiotics were continued while he remained neutropenic. He had a fever to 100.6 on [2174-4-9] and cultures were drawn from his dialysis catheter which were positive for GPCs in chains. His catheter was pulled and he was continued on vancomycin. . # Pericardial Fat Pad: On echo on [2174-3-24] there was concern for pericardial effusion because the echo showed a new anterior pericardial effusion with complex echodensity. No evidence of tamponade physiology was seen on the echo. His repeat echo showed that the effusion was actually a fat pad. . # Alcoholism/Cirrhosis: He was known to drink a bottle of alcohol per night. He initially required 10 mg IV diazepam several times and started on a CIWA scale. On RUQ imaging for persistent elevation of his bilirubin, cirrhosis was noted. More than likely his cirrhosis was secondary to alcoholism and he had poor clearance of his bilirubin (from reabsorption from pooled blood). . # Elevated Glucose: He initially had glucose's in the 400??????s in the setting of getting steroids. His insulin coverage was briefly switched to an insulin drip, and he was subsequently converted to subcutaneous insulin based on his requirements. # Goals of care: Pt remained in coma. His overall clinical status continued to decline over the course of hospitalization, with evolution of multi-system organ failure including increased pulmonary ventilatory requirements, persistant renal failure, LFTs continued to increase and he developed recurrent bacteremia (initially MSSA, then VRE). He was given 1 dose of daptomycin for VRE coverage. Given his multiple organ failure, worsening ventilatory requirements and persistent altered mental status, a family meeting was held and decision made to focus efforts on patient comfort beginning [2174-4-12] AM. The patient quietly expired on [2174-4-14] with family at the bedside. Medications on Admission: - Metformin 500mg [Hospital1 ] - Metoprolol tartrate 50mg [Hospital1 ] - Cimetidine 100mg [Hospital1 ] - Amlodipine 10mg daily - Lisinopril 2.5mg daily Discharge Medications: Deceased Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438]	[ "427.32", "790.7", "291.81", "577.0", "286.6", "041.09", "571.2", "041.04", "276.4", "041.11", "277.88", "272.4", "V70.7", "205.00", "414.01", "729.73", "432.1", "427.31", "276.0", "401.9", "V09.80", "413.9", "V49.86", "250.00", "284.1", "303.91", "786.30", "999.31", "518.81", "274.9", "349.82", "570", "E933.1", "434.91", "584.5" ]	icd9cm	[ [ [] ] ]	[ "38.95", "31.1", "99.25", "99.62", "96.72", "39.95", "96.6" ]	icd9pcs	[ [ [] ] ]	13886, 13895	4508, 13638	372, 384	13947, 13957	4082, 4082	14014, 14151	3237, 3375		13853, 13863		13916, 13926		13664, 13830			13981, 13991									3390, 3390																			1717, 2261					266, 334										440, 1645							4098, 4485		3404, 4063						2387, 2498	2514, 3221
14,131	138,678	10742+56171	Discharge summary	report+addendum	Admission Date: [2118-2-22] Discharge Date: [2118-3-11] Date of Birth: [2058-4-29] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 1990] Chief Complaint: Transfer from OSH for further evaluation of delirium Major Surgical or Invasive Procedure: None History of Present Illness: 59F with CAD s/p multiple PCIs, ischemic CHF, Type I DM, Hx of Anoxic Brain Injury, Anxiety, Depression who presents with altered mental status sp ICD placement for ventricular tachycradia. Per husbands report 5 weeks ago pt presented to [Hospital1 ] with small MI per his report. Was going to be DCd home when she had an anxiety attack which led to VT and transfered to ICU for one week. One week later transfered to rehab hospital where on telemetry had high amount of ventricular arrythmia. Cardiology at rehab thought she should have ICD placed. Patient was admitted on [2118-2-8] to [Hospital6 ] for prophylactic placement of an ICD given history of ventricular tachycardia. This placement was c/b small hematoma at ICD site and episode of VT leading to ICD to fire. Patient was transfered to ICU at OSH where patient had two further epidoses of VT that required ICD firing. Briefly, while hospitalized patient started on mexiletine for VT however liver enzymes trended up so this medication was stopped. Metoprolol was also increased to 100mg PO TID. During admission patient also found to have prolonged QT so levaquin, amiodarone and xanax were stopped. At transfer patient has been tachycardia free for one week last episode of VT [2-13]. Further while hospitalized at the OSH Celexa, Namenda and xanax were stopped given patients delirium. Abilify and Remeron were started. Patient's agitation appears to have been treated with restraints and benzodiazepines. During that ICU stay husband noticed increased anxiety and more delirium. No success in understanding etiology of delirium. Poor PO intake. Family asked by team there about making patient DNR/DNI. Family contact[Name (NI) ] Dr. [Last Name (STitle) 911], who has treated patient in the past and he had patient transferred here for further evaluation of her delirium. At the outside hosptial no infections identified or treated. CT scan of head when admitted with MI [2118-1-20] and repeated on Sunday [2117-2-20] husband notes a difference concerning for stroke. . On arrival to MICU, patient agitated, yelling. States she has pain in her arms and legs, but unable to tell more about it. . Review of systems: Unable to assess given patients mental status. Past Medical History: - CAD s/p anterior MI, multiple PCIs and history of left main thrombosis during last cath in [3-/2112]; with thrombotic event developed 10 minute asystolic arrest. Since then she has had positive stress test, not deemed to be intervened upon due to high risk. - Ischemic CHF with most recent known EF 20-25% in [Month (only) 1096] [2117]. - PVD s/p fem-[Doctor Last Name ] bypass. - DM type I - CKD - baseline creatinine 2.5-3 - Legally blind due to diabetic retinopathy - Anoxic brain injury resulting from PEA arrest in cath as above. - Memory and word finding difficulties of unclear etiology; has been evaluated by neurology and cognitive neurology. - Diabetic neuropathy - Hypothyroidism - Anxiety - Depression - s/p carpal tunnel surgery - ?severe pulmonary hypertension Social History: She has one son. She finished a bachelor's degree in college, is married, and lives with her husband. She is a nonsmoker and does not drink any alcohol. At baseline uses a walker as a result of her diabetic neuropathy and can get around the house on her own. Thinking is clear, not as good as 10-15 years ago. Per husband. Family History: Her mother died at 50 of heart-related illness. Physical Exam: Vitals: Afebrile, 74, 147/57 General: Angry, agitated. Eyes shut, does not open spontaneously to command. Shouting nonsensically - often disinhibited and swearing at others. Often shouting for "[Doctor First Name 17]" or "[Doctor First Name ]". Repeats what is said to her in mocking tone. Sometimes with word finding difficulties or replacement with similar sounding words. At times when threatening speech. HEENT: Sclera anicteric, PERRL 4->3 though only can see eyes when lids forced open. MMM, oropharynx clear. Neck: supple, JVP not elevated, no LAD. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi, though poor insiratory effort and will only permit anterolateral exam currently. CV: Regular rate and rhythm, normal S1 + S2, [3-12] SM at LUSB without radiation. L sided ICD with overlying ecchymosis, area somewhat firm, no erythema or warmth or fluctuance. Ecchymosis over left chest/breast. Abdomen: soft, appears non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: slightly cool, well perfused, 2+ DP pulses, no clubbing, cyanosis. Trace LUE edema of upper arm, minimal LE edema. R heel with deep decubitus with eschar. Neuro: unable to participate in exam. Mental status and speech as above. Moves all extremities, but unable to formally test strength. States she knows where she is and date but refuses to tell me. States she has been in the hospital for ten years. Pertinent Results: Labs on Admission: [2118-2-22] 06:28PM GLUCOSE-262* UREA N-44* CREAT-2.4* SODIUM-145 POTASSIUM-4.6 CHLORIDE-109* TOTAL CO2-27 ANION GAP-14 [2118-2-22] 06:28PM ALT(SGPT)-100* AST(SGOT)-74* LD(LDH)-365* TOT BILI-0.6 [2118-2-22] 06:28PM ALBUMIN-3.0* CALCIUM-8.6 PHOSPHATE-3.9 MAGNESIUM-2.5 [2118-2-22] 06:28PM VIT B12-GREATER TH FOLATE-GREATER TH [2118-2-22] 06:28PM TSH-4.9* [2118-2-22] 06:28PM FREE T4-1.9* [2118-2-22] 06:28PM WBC-9.0# RBC-3.83# HGB-11.6 HCT-36.3# MCV-95 MCH-30.4 MCHC-32.1 RDW-15.3 [2118-2-22] 06:28PM NEUTS-73.3* LYMPHS-18.1 MONOS-6.2 EOS-2.1 BASOS-0.2 [2118-2-22] 06:28PM PLT COUNT-176 [2118-2-22] 06:28PM PT-10.6 PTT-22.8 INR(PT)-0.9 Labs on Discharge and Pertinent Labs throughout hospitalization: [2118-3-9] 05:05AM BLOOD WBC-5.8 RBC-2.70* Hgb-8.0* Hct-26.2* MCV-97 MCH-29.7 MCHC-30.6* RDW-18.9* Plt Ct-294 [2118-3-6] 05:46AM BLOOD Neuts-79.7* Lymphs-15.9* Monos-2.9 Eos-1.4 Baso-0.1 [2118-3-9] 05:05AM BLOOD Plt Ct-294 [2118-3-9] 05:05AM BLOOD Plt Ct-294 [2118-3-9] 05:05AM BLOOD Glucose-143* UreaN-28* Creat-1.5* Na-146* K-3.8 Cl-112* HCO3-26 AnGap-12 [2118-3-8] 06:00AM BLOOD LD(LDH)-404* [2118-2-25] 03:48AM BLOOD Lipase-10 [2118-2-25] 05:29PM BLOOD CK-MB-NotDone cTropnT-0.01 [2118-2-25] 03:48AM BLOOD CK-MB-NotDone cTropnT-0.02* [2118-3-9] 05:05AM BLOOD Calcium-8.3* Phos-3.6 Mg-2.3 [2118-2-28] 07:45AM BLOOD calTIBC-142* Ferritn-1209* TRF-109* [2118-3-9] 05:05AM BLOOD TSH-5.6* [2118-2-22] 06:28PM BLOOD TSH-4.9* [2118-3-9] 05:05AM BLOOD T4-6.2 [2118-2-22] 06:28PM BLOOD Free T4-1.9* [2118-3-8] 01:54PM BLOOD [Doctor First Name ]-NEGATIVE [2118-2-26] 06:30AM BLOOD CRP-101.2* [2118-2-26] 06:30AM BLOOD ESR-64* [2118-2-26] 04:24PM BLOOD Lactate-1.6 Micro: [2118-3-2] BLOOD CULTURE Blood Culture, Routine-neg [2118-3-2] BLOOD CULTURE Blood Culture, Routine-neg [2118-3-2] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-neg [2118-3-2] BLOOD CULTURE Blood Culture, Routine-neg [2118-3-1] BLOOD CULTURE Blood Culture, Routine-neg [2118-2-28] BLOOD CULTURE Blood Culture, Routine-neg [2118-2-28] BLOOD CULTURE Blood Culture, Routine-neg [2118-2-28] BLOOD CULTURE Blood Culture, Routine-neg [2118-2-27] URINE URINE CULTURE-neg [2118-2-27] BLOOD CULTURE Blood Culture, Routine-neg [2118-2-27] BLOOD CULTURE Blood Culture, Routine-neg [2118-2-26] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-neg [2118-2-26] URINE URINE CULTURE-neg [2118-2-26] BLOOD CULTURE Blood Culture, Routine-neg [2118-2-26] BLOOD CULTURE Blood Culture, Routine-neg [2118-2-25] FOOT CULTURE WOUND CULTURE [NOTE THIS WAS A SUPERFICIAL SKIN SWAB)-FINAL {MRSA} INPATIENT [2118-2-23] BLOOD CULTURE Blood Culture, Routine-neg [2118-2-23] BLOOD CULTURE Blood Culture, Routine-neg [2118-2-23] URINE URINE CULTURE-neg [2118-2-23] URINE URINE CULTURE-neg [2118-2-22] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-neg [2118-2-22] MRSA SCREEN MRSA SCREEN-positive ECG: [2118-2-22] QT/QTc 496/497 [2118-3-7] QT/QTc 444/470 Studies: CT head ([2-23]): No focal infarct or other acute intracranial abnormality is present Right foot films ([2-25]) Three views of the right foot demonstrate severe lateral deviation of the first digit and mild deviation of the second digit. There are mild degenerative changes at the first MTP joint. There is extensive vascular calcification. There is an old fracture deformity of the fifth metatarsal. The wound has not been marked, and it is difficult to assess for location of ulcer. There is mild irregularity about the soft tissues of the calcaneus. It is unclear as to whether this represents the soft tissue wound site. There is osteopenia, and there are mild degenerative changes in the mid foot. KUB (done for N/V) [2-26] Three views of the abdomen demonstrate scattered foci of air within the colon and the stomach. The colon demonstrates a moderate amount of stool. Air is also seen in the rectum. There is no colonic distention or free intraperitoneal air identified. No air-fluid levels seen on the left lateral decubitus. CXR [2-26] - PA/Lateral Comparison is made to the prior study from [2118-2-22]. A pacer AICD is present in the left chest wall with two leads. Heart is top normal in size. Mediastinum within normal limits. There is mild atelectasis in the lung bases. B/l LENIs: IMPRESSION: No evidence of DVT bilaterally in the lower extremities. TTE: The left atrium and right atrium are normal in cavity size. The right atrial pressure is indeterminate. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with focal severe hypokinesis of the distal half of the anterior septum and anterior walls, and distal inferior wall.. There is an apical left ventricular aneurysm with mild dyskinesis. The remaining segments contract normally (LVEF = 35 %). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal with focal hypokinesis of the apical free wall. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild to moderate ([2-5]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with regional left and right ventricular systolic dysfunction c/w CAD. Pulmonary artery systolic hypertension. Mild-moderate mitral regurgitation. Compared with the report of the prior study (images unavailable for review) of [2112-4-4], left ventricular systolic function appears improved with new focal right ventricular apical hypokinesis and increased pulmonary artery systolic pressure. Brief Hospital Course: Assessment and Plan: 59F with CAD s/p multiple PCIs, ischemic CHF, Type I DM, Hx of Anoxic Brain Injury, Anxiety, Depression who presents with altered mental status sp ICD placement for ventricular tachycradia. . # Delirium: While hospitalized at OSH and at [Hospital1 18], mutiple episodes of hallucinations/agitation/anxiety with intermittent lucidity. Felt to be multifactorial in the setting of recent hosptialization, poor PO intake, and at least five psychiatric medications, all in the setting of a poor substrate (i.e. Hypoxic Brain Injury), however, pt's baseline is alert and oriented x3 and highly functioning. B12/folate/RPR wnl. TSH was high, but on synthroid, and unclear how to interpret while hospitalized. OSH records indicating ?thalamic stroke were obtained, and read by [Hospital1 18] radiologist who said that in the setting of a noncontrast study, not ideal study, but nothing to suggest acute thalamic stroke. Infection was ruled out (though she did spike fevers on two occasions and was intermittently on IV abx, these were stopped >1 week prior to discharge because infectious workup was negative and she remained clinically stable with no recurrence of fever after abx were d/c'ed). Psychiatry, Neurology, and Geriatrics followed her case closely while she was hosptialized. She was originally on PRN ativan, but was felt to be having a paradoxical effect to the ativan. She then had a trial of depakote (stopped because LFT's began to trend up after having previously normalized in the setting of stopping mexilitine), and a trial of low-dose seroquel (ultimately not effective enough). The major barrier to choosing an appropriate medication was attention to QTc, as she at one point had a QTc of 600 at the OSH in the setting of being loaded on amiodarone. Her QTc on admission was close to 500, and eventually trended down to 444, at which point the seroquel was tried. Ultimately, after extensively discussing the options with the family and the many consulting teams, she was tried on small doses of [Hospital1 ] with close monitoring of the QTc. On discharge, QTc was 470-500 and patient was tolerating [Hospital1 ] [Hospital1 ] c good effect. Patient was oriented to self and place at most times. She did still have periods of confusion and agitation but they were rare and treated with reassurance and redirection rather than additional medications. -WEAN [Name (NI) ] AS PT STABILIZES/IMPROVES . # Ventricular arrhythmias sp ICD placement: Patient had no episodes of ventricular tachycardia while hospitalized at [Hospital1 18], though she had several episodes at OSH. She was continued on metoprolol, and K, Mg were judiciously repleted in the setting of chronic renal insufficiency. She had daily ECG's to monitor QTc in the setting of medication adjustments as above and remained on telemetry throughout her hospitalization without event. Pt was noted to be Vpaced continuously, ppm set at 75 bpm. . # Depression/Anxiety: All psychiatric medications have been held in the setting of delirium as described above with the exception of [Hospital1 ]. Pt did endorse depressive symptoms as she became more alert. Psychiatry felt that pt might benefit from a nonactivating antidepressant (?celexa), but this was deferred to rehab setting as it was felt that starting an additional psychiatric medicine at this time might complicate her picture. -CONSIDER RESTARTING SSRI AS PT STABILIZES CLINICALLY -CONSIDER REFERRAL TO PSYCHIATRY ON DISCHARGE . # ? Extrapyramidal effects: pt noted to have some mild cog-wheeling on exam after starting [Hospital1 ]. Pt reports that she has tremor at baseline and that is no worse currently. This was discussed with psychiatry who strongly recommended NOT starting benztropine as this can cause psychosis and agitation. Instead, they recommended following her clinical exam and considering tapering [Hospital1 ] or switching to seroquel if worsening EPS. . # Anemia: Stable Hct throughout hospitalization. Likely [3-8] anemia of chronic disease [3-8] renal dysfunction. Continued epogen as inpatient. . # Elevated Liver Function: LFTs were elevated on admission in the setting of mexelitine. Normalized after this medication was held. LFT's also transiently trended up in the setting of depakote, but normalized when this was stopped with the exception of LDH which remained in the 400s. Upon review pt has had elevated LDH for many years. -CONSIDER FURTHER W/U OF ELEVATED LDH . # CAD s/p multiple PCI. Continued [Last Name (LF) ], [First Name3 (LF) ], statin. . # Chronic systolic CHF, ischemic. Echo showed EF 35%. Continued beta blocker and [Last Name (un) ]. Lasix was held as pt felt to not be volume overloaded clinically and having poor PO intake for most of her hospitalization. On the day of discharge to rehab pt was noted to have crackles diffusely in the setting of increased PO intake over past few days. Thus, pt was restarted on home lasix dose of 80 daily. Pt will need close f/u of volume status at rehab and possibly further titration of lasix. . # Type 1 DM: Poorly controlled due to fluctuating eating habits. Followed by [Last Name (un) ] in the hospital and lantus and sliding scale adjusted. Pt will likely require up-titration as she eats more. . # CKD: Baseline Creatinine has ranged 2.0 to 3.0 since [2112]. Secondary to Diabetes. Creatinine trended down as low as 1.4 during this hospitalization, and was 1.6 on discharge. . # Coccyx/Heel Ulcerations: Chronic. Patient was seen by podiatry to be sure that these wounds were not acutely infected, and they agreed that the wounds were not concerning for active infection. She will require daily dressing changes after discharge. Medications on Admission: ON TRANSFER FROM [Hospital1 ] TO [Hospital1 18] PT WAS ON THE FOLLOWING: Gabapentin 100 mg daily Abilify 5 mg daily Clonazepam 1 mg at 1800 daily Ativan 1 mg IV prn Synthroid 100 mcg PO daily (50 IV if no PO) Florastar 250 mg [Hospital1 ] Metoprolol 100 mg PO TID (5mg IV Q6h if no PO) [Hospital1 ] 325 mg daily [Hospital1 ] 75 mg daily Imdur 30 mg daily Lasix 80 mg PO daily (40 IV if no PO) Cozaar 25 mg [Hospital1 ] Protonix 40 mg PO daily Heparin 5000 units SC daily Mag oxide 400 mg [Hospital1 ] Regular insulin sliding scale Levemir 8 units QAM, 6 units QHS Discharge Medications: 1. Clopidogrel 75 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine 88 mcg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 3. Olanzapine 2.5 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 4. Olanzapine 5 mg Tablet [Hospital1 ]: One (1) Tablet PO HS (at bedtime). 5. Valsartan 160 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily): hold for SBP <110. 6. Atorvastatin 40 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO DAILY (Daily). 8. Thiamine HCl 100 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 50 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day): hold for HR <60 or SBP <100. 10. Multivitamin Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 12. Polyethylene Glycol 3350 17 gram/dose Powder [Last Name (STitle) ]: One (1) PO DAILY (Daily). 13. Senna 8.6 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Last Name (STitle) ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 15. Isosorbide Mononitrate 10 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day). 16. Epogen 10,000 unit/mL Solution [Last Name (STitle) ]: One (1) Injection every 10 days. 17. Insulin Glargine 100 unit/mL Cartridge [Last Name (STitle) ]: as below Subcutaneous twice a day: 4 Units qam and 12 Units qpm. 18. Cepacol Sore Throat Mucous membrane 19. Colace 100 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO twice a day. 20. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [Last Name (STitle) ]: [2-5] Adhesive Patch, Medicateds Topical DAILY (Daily) as needed for back pain: 12 hours on, 12 hours off. 21. Acetaminophen 500 mg Tablet [Month/Day (2) ]: One (1) Tablet PO Q6H (every 6 hours) as needed for fever, ha, pain. 22. Furosemide 80 mg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Acute Delirium 2. Ventricular Tachycardia s/p ICD placement 3. Diabetes Mellitus Type I 4. Anoxic Brain Injury 5. Chronic Kidney Disease 6. Chronic Systolic Congestive Heart Failure SECONDARY DIAGNOSIS: 1. PVD s/p fem-[Doctor Last Name ] bypass. 2. Legally blind due to diabetic retinopathy 3. Diabetic neuropathy 4. Hypothyroidism 5. Anxiety 6. Depression 7. s/p carpal tunnel surgery Discharge Condition: Mental Status:Confused - always Activity Status:Out of Bed with assistance to chair or wheelchair Level of Consciousness:Alert and interactive Discharge Instructions: FOR PATIENT: You were transferred to [Hospital1 18] on [2118-2-22] with altered mental status. We believe this is due to the many psychiatric medications you were on before your hospitalization. You were seen by the psychiatry team, the geriatrics team, and the neurology team while you were in the hospital. You also have a long "QTc" interval, which we discussed with your family members. It is a heart condition that could predispose you to arrhythmias. We changed some of your medications based on this. Your medication list has been completely changed and simplified. ONLY TAKE THE MEDICATIONS LISTED, AND DO NOT RESUME ANY OF YOUR PREVIOUS MEDICATIONS NOT ON THIS LIST (this is very important as some of the medications you were taking may be harmful for you now). FOR REHAB: -Please check vital signs per your routine -Please check daily EKG to confirm no QTc prolongation -please continue monitoring on telemetry, pt to see electrophysiology on [2118-3-25] -Please check chem 7 daily and replete K to 4 and Mg to 2 given arrhythmias. Creatinine currently at baseline of 1.6, home lasix dose restarted on [2118-3-11]. Sodium has trended up on several occasions, thought to be [3-8] poor PO intake and has improved with gently rehydration with D5W. -Please check plts and ptt biweekly to confirm no HIT or prolongation of PTT in setting of sc heparin -Please provide PT and OT -Please consult geripsych asap -Please consider consulting endocrine, endocrine has been following her here while hospitalized -Please check daily weights and record careful I/O. Pt may require titration of lasix. Pt had been on 80mg PO daily at home which had been held [3-8] poor PO intake until the day of discharge when pt was noted to have crackles on exam, at which time lasix restarted at previous dose. -Please transport pt to her cardiology appointments as listed below -Please arrange for pt to see her pcp [Name Initial (PRE) 176] 1 week of discharge -on discharge, please discuss appropriate psychiatric followup with [Female First Name (un) ]-psych specialist who has been seeing her at [Hospital 100] Rehab -Please provide patient with an updated list of her medications when she leaves as she is on VERY different medicines now than she was on when she was first hospitalized -Please provide patient with diabetic teaching WOUND CARE: 1. Commercial wound cleanser or normal saline to irrigate/cleanse all open wounds. 2. Pat the tissue dry with dry gauze. 3. Apply moisture barrier ointment to the peri wound tissue with each DRG change. 4. Apply protective barrier wipe to peri wound tissue and air dry. 5. Bilateral Heels: DSD and wrap with Kerlix daily. 6. Bilateral toes: cleanse with commercial wound cleanser gently. Pat dry. Place 2x2 in-between each toe to allow aeration daily. 7. Left heel callus: apply Aloe Vesta ointment [Hospital1 ]. 8. Right anterior leg: Apply small amount of DuoDerm wound gel, cover with Mepilex dressing. Change every 3 days. This dressing is also used to protect skin from trauma when patient moves. 9. Left anterior leg: Mepilex placed to protect from trauma with patients non-purposeful movement. Change 1x/week . 10. Bilateral Glutealis: Apply Criti-Aid Clear, reapply after each three cleansing. 11. Fecal Incontinence: if stooling is liquid, consider placement of FIP to protect surrounding skin from stool enzymes. Followup Instructions: Please transport patient to the following appointments: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. Phone:[Telephone/Fax (1) 62] Date/Time:[2118-3-25] 3:20 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2118-4-14] 2:00 3. Please arrange for pt to see her pcp [Name Initial (PRE) 176] 1 week of discharge 4. Pt to be seen by [Female First Name (un) ]-psych while inpatient at [Hospital ] rehab, on discharge, please discuss appropriate followup with [Female First Name (un) ]-psych specialist who has been seeing her at [Hospital 100] Rehab Completed by:[2118-3-12] Name: [Known lastname 6228],[Known firstname ] Unit No: [Numeric Identifier 6229] Admission Date: [2118-2-22] Discharge Date: [2118-3-11] Date of Birth: [2058-4-29] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 429] Addendum: Please add to PHYSICAL EXAM section: EXAM ON DISCHARGE: psych: generally alert and oriented x2-3 and able to answer questions appropriately. Some moments of confusion especially in early morning and late afternoon. At those times she was oriented to self only and was generally very agitated, screaming for her husband. Discharge Disposition: Extended Care Facility: [Hospital6 609] for the Aged - MACU [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 430] MD [MD Number(2) 431] Completed by:[2118-3-12]	[ "276.7", "V58.67", "244.9", "707.14", "707.22", "443.9", "794.8", "426.82", "428.22", "362.01", "707.23", "369.4", "285.21", "276.0", "348.1", "250.63", "585.4", "410.92", "416.8", "E947.8", "707.07", "357.2", "414.01", "996.72", "290.40", "E939.3", "V45.82", "250.53", "V45.02", "276.2", "428.0", "427.1", "250.43", "707.03", "300.4", "333.90", "349.82" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	25612, 25833	11387, 17131	348, 354	20573, 20573	5384, 5389	24167, 25304	3822, 3871		17773, 20027		20137, 20137		17157, 17750			20742, 23103									3886, 5365																			2597, 2646					256, 310							23115, 24144			382, 2578		25323, 25589		20363, 20552				20156, 20342	5403, 11364		20587, 20718				2668, 3464	3480, 3806
18,370	147,068	20439	Discharge summary	report	Admission Date: [2104-3-8] Discharge Date: [2104-3-11] Date of Birth: [2055-3-8] Sex: M Service: CCU/MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 48 year-old male with a family history of coronary artery disease presenting with chest pain at rest after eating dinner about 8 out of 10 substernal chest pain associated with nausea and diaphoresis, but no shortness of breath. The patient had stuttering chest pain at rest lasting one to two minutes on and off throughout the day and then after dinner his pain increased to an 8 out of 10 and was constant at 6:00 p.m. He was taken to the [Hospital1 ] Emergency Department and transferred at 8:30 p.m. for emergent cardiac catheterization at [Hospital1 1444]. He had ST elevations anteriorly and his catheterization revealed 100% thrombotic occlusive lesion at the mid left anterior descending coronary artery. He had a percutaneous transluminal coronary angioplasty and cipher stent placed in his mid left anterior descending coronary artery. The patient denies any other history of chest pain or exertional symptoms. At baseline he exercises on an elliptical machine for 30 minutes at a time without an symptoms. He denies any paroxysmal nocturnal dyspnea, orthopnea or lower extremity edema. PHYSICAL EXAMINATION: Temperature 98.0. Heart rate 70. Blood pressure 116/76. Respirations 18. Satting 100% on 2 liters nasal cannula. Generally he is in no acute distress, alert and oriented times three. HEENT mucous membranes are moist. JVP at 14 cm. Cardiovascular regular rate and rhythm. No murmurs, rubs or gallops. Pulmonary clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended. Normoactive bowel sounds. Extremities no edema. 2+ dorsalis pedis pulses. Right groin with arterial and venous sheaths. No hematomas. No bruits. LABORATORY: White blood cell count 11, hematocrit 44.6, platelets 250. Chemistries are 136, 3.9, 107, 24, 15, creatinine .9, glucose 181, CK is 125, troponin I is 0.24. Cardiac catheterization revealed right atrial pressure of 7, right ventricular pressure of 24/7. Pulmonary artery pressure of 30/17, pulmonary capillary wedge pressure of 24. Cardiac output of 4.21, cardiac index of 2.39. Left anterior descending coronary artery had a mid thrombotic occlusive lesion just distal to the first diagonal. The patient underwent percutaneous transluminal coronary angioplasty and a 3.5 cipher stent. Electrocardiogram precatheterizatin was normal sinus rhythm at 60 with left axis deviation and slight intraventricular delay. T wave flattening in 3 and AVL, hyperacute Ts with some ST elevations in V2 through V6. Echocardiogram showed an ejection fraction of 30 to 35% with anterior hypokinesis. HOSPITAL COURSE: 1. Anterior ST elevation myocardial infarction: The patient had a percutaneous transluminal coronary angioplasty and stent of mid left anterior descending coronary artery lesion. He was started on aspirin and Plavix, Toprol XL. He did not tolerate an ace inhibitor as his blood pressures fell to 80/50, so ace inhibitor was discontinued and can be reinstated as an outpatient if his blood pressure tolerates. He was started on Coumadin 5 mg q day for risk of embolism from anterior myocardial infarction. He will go home on home Lovenox injections until his INR is greater then 2. The patient also had several runs of nonsustained ventricular tachycardia within 24 hours of his myocardial infarction. He had a normal signal averaged ECG with the electrophysiology laboratory and he is to follow up in three to four weeks to have a T wave alternans test and follow up with Dr. [Last Name (STitle) ] of the Electrophisiology Service. 2. Glucose intolerance: The patient's glucose levels were elevated in the hospital, but not diagnostic of diabetes. He should follow up with his primary care physician regarding any treatment necessary. DISCHARGE DISPOSITION: Stable. DISCHARGE STATUS: The patient will be discharged home with home Lovenox teaching. FOLLOW UP PLANS: 1. The patient is to follow up with his primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 18323] on Friday [2104-3-14] at 11:45 a.m. for his INR check. He is also to discuss with his doctor any treatment necessary for his elevated blood sugars. 2. He si to follow up with his cardiologist Dr. [First Name4 (NamePattern1) 919] [Last Name (NamePattern1) 911] on [3-31] at 10:30 a.m. in the [Hospital Ward Name 23] Building [Location (un) ]. He is to call [Telephone/Fax (1) 4022] to finish his registration the day or the day after he is discharged from the hospital. 3. He is to come for his T wave alternans test on Monday [4-7] at 1:15 p.m. on the [Hospital Ward Name 517] [Location (un) ] of the [Hospital Unit Name 54755]. 4. He is to follow up with his electrophysiologist Dr. [Last Name (STitle) ] after his T wave alternans test and to call [Telephone/Fax (1) 285] for an appointment. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg po q day. 2. Plavix 75 mg po q day. 3. Lipitor 80 mg po q day. 4. Toprol XL 25 mg po q day. 5. Lovenox 16 mg subq b.i.d. until INR is greater then 2.0 and then maybe discontinued. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 5214] Dictated By:[Last Name (NamePattern1) 5819] MEDQUIST36 D: [2104-3-11] 01:57 T: [2104-3-13] 08:21 JOB#: [Job Number 54756]	[ "271.3", "V17.3", "410.11", "414.01", "429.9" ]	icd9cm	[ [ [] ] ]	[ "36.07", "88.56", "36.01", "99.20", "37.23" ]	icd9pcs	[ [ [] ] ]	3963, 5052								5075, 5523					2790, 3939																								1321, 2773																					168, 1298
30,020	160,341	32209	Discharge summary	report	Admission Date: [2123-12-20] Discharge Date: [2123-12-27] Date of Birth: [2046-6-27] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1042] Chief Complaint: Respiratory Failure Major Surgical or Invasive Procedure: Intubation History of Present Illness: 77M with a history of CODP, CHF presented to [Hospital 1562] hospital with respiratory distress. Per his daughter, the patient has a h/o severe COPD w/ chronic bronchitis, and has had several COPD flares in the past few months, requiring several courses of antibiotics. She notes that he has had increasing productive cough and fatigue for a few days PTA. She also notes increased swelling around his eyes. On the evening of admission, she states that he developed abrupt onset shortness of breath and increased respiratory rate while seated at te dinner table and "looked [Doctor Last Name 352] and terrible", therefore she called 911-> to OSH ED. Of note, she states the he is compliant with his medications. [Hospital1 1562] ED: Initial Vitals: BP 132/95, HR in 90's, RR 32, satting 76% on a nonrebreather. UA negative. CXR: Cardiomegaly, lungs clear but hyperexpanded. He was given etomidate 30, vecuronium 8, Versed 4, and intubated with a #8 (24 at lips). He was also given solumedrol 125, combivent inh, ceftriaxone 1 gm, azithromycin 500 mg. He was transferred to [Hospital1 18] ED for further evaluation and treatment. . [Hospital1 18] ED Course: Arrived via ambulance, intubated. Initial vitals: T 98.9, 87, 117/87, 15, 100%. ABG: 7.26/68/95/32. Lactate 2.3->2.0, WBC 16.5, Cr 1.8, CE's negative x1. EKG without signs of ischemia. CXR clear. UA negative. Given 2L NS, Vancomycin 1 gram, Aspirin 600 mg PR, albuterol nebs. . ROS: Unable to obtain; pt intubated Past Medical History: CHF (EF = 35% per old d.c summary) COPD Obesity Paroxismal atrial fibrillation +tobacco use ischemic cardiomyopathy CAD diverticulosis HTN Hyperlipidemia Chronic kidney disease (Cr = 1.8 on [8-24]) h/o benign colonic polyps s/p removal Anemia (Fe deficiency) Thoracic aortic aneurysm (4.9 x 5 cm) Social History: Current smoker, >60pk yr history, currently smoking 1ppd. lives with wife and 2 daughters. [Name (NI) ] etoh. retired. Family History: Non-contributory Physical Exam: VS: Temp: 98 BP:132/66 HR:73 RR:24 O2 sat: 92% vent: AC 600 x 18, PEEP 8, 70% GEN: obese male, sitting up in chair, NAD HEENT: NC, AT, EOMI, sclera anicteric NECK: no supraclavicular or cervical lymphadenopathy. Unable to assess JVD given habitus. RESP: CV: Heart sounds distant. RR, S1 and S2 wnl. ABD: obese, nd, +b/s, soft EXT: dopplerable pulses, ext warm/well perfused; 1+ bilateral LE edema, SKIN: no rashes/no jaundice. Dry skin over LE's. Pertinent Results: Admission Labs: [2123-12-20] 04:20AM LACTATE-2.3* [2123-12-20] 04:25AM URINE RBC-[3-22]* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 RENAL EPI-0-2 [2123-12-20] 04:25AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2123-12-20] 04:25AM WBC-16.5* RBC-5.14 HGB-12.7* HCT-40.6 MCV-79* MCH-24.7* MCHC-31.2 RDW-16.8* [2123-12-20] 04:25AM CALCIUM-7.6* PHOSPHATE-3.8 MAGNESIUM-2.0 [2123-12-20] 04:25AM CK-MB-7 proBNP-1341* [2123-12-20] 04:25AM cTropnT-0.06* [2123-12-20] 04:25AM CK(CPK)-164 [2123-12-20] 07:09AM DIGOXIN-0.7* [2123-12-20] 11:38AM CK-MB-5 cTropnT-0.03* [2123-12-20] 11:38AM CK(CPK)-113 [2123-12-20] 09:42PM CK-MB-4 cTropnT-0.03* . Chest CT scan [12-20] 1. No evidence of PE. 2. 4.9 cm suprarenal abdominal aortic aneurysm. 3. Right lower lobe consolidation with volume loss and air bronchograms and associated effusion. This most likely represents atelectasis given the rapid development when multiple plain radiographs obtained today are compared. However, superinfection cannot be excluded. 4. Cardiomegaly with CHF. . EKG [12-20] Sinus rhythm. Left atrial abnormality. Right axis deviation. Right bundle-branch block. Delayed anterior precordial R wave progression. Cannot exclude prior anterior myocardial infarction. No previous tracing available for comparison . Bronchial Lavage NEGATIVE FOR MALIGNANT CELLS. Brief Hospital Course: A/P: 77M with history of COPD, afib, CAD admitted with respiratory failure. . # Respiratory failure: Per report, intubated for hypoxic resp failure at OSH; however, had hypercapnia on initial ABG at [Hospital1 ], c/w COPD flare (likely w/ elevated CO2 levels at baseline). Differential includes COPD exacerbation vs PE (given acute onset, Rt axis on EKG). No evidence of PNA, ARDS or other lung pathology on initial CXR other than chronic changes of COPD; however, CTA on [12-21] was negative for PE and showing RLL collapse. Bronchoscopy on [12-21] was unremarkable for obstructing lesion or other pathology. BAL and cytology were collected. Nasopharyngeal aspirate negative for influenza. Patient is clinically stable and ready for extubation. -extubated [12-22] -Cont ceftriaxone/azithro to cover CAP/COPD exacerbation - completed azithro [12-23], recommend 3 more days of ceftriaxone -Steroids: Rapid taper - now off -Inhalers -f/u micro data -f/u OSH micro - none available -f/u OSH labs (CBC, ABG, CHEM 10) The patient was managed for his COPD exacerbation with pulse steroids, antibiotics, and intensifying his CODP inhaler therapies. He gradually improved and on discharge was nearly at baseline. . # CAD: Enzymes negative X3. Has CAD/ischemic CM by report. -cont aspirin, statin. -Consider adding BB, ace-I prior to d/c . # Rhythm: Currently in sinus, has h/o PAF. Not on coumadin at home. -d/w PCP reason for not anticoagulation -Cont aspirin -continue to monitor on tele . # Pump: h/o CHF, EF 35% by prior d/c summary. Slightly overloaded by most recent CXR s/p volume resuscitation. -obtain OSH records -likely will need to diurese tomorrow -Digoxin subtherapeutic, will continue. . # Hyperglycemia: in setting of steroids. No h/o DM. -QID fingersticks, HISS, titrate insulin PRN for tight control . #CKD: At baseline. -gentle IVF in preparation for CTA -trend Cr -place foley, follow strict I/Os -f/u UA, Ucx . #Leukocytosis: In setting of steroids; may be due to steroids vs representative of underlying infection. + left shift. -Trend WBC, f/u diff -f/u micro data as above -cont empiric abx for now -obtain initial CBC from OSH presentation . # Hyperlipidemia: cont statin . # HTN: holding CCB at present. Consider BB/Ace-I prior to discharge given CHF . # F/E/N: IVF as above. Replete lytes PRN. NPO at present. . # PPx: Bowel regimen, PPI, sq Heparin . # Access: PIV's: 1 20g and 2 18g's . # Code Status: Full (confirmed w/ wife and daughter-[Name (NI) 3508] on admit) Medications on Admission: Albuterol prn Aspirin 81 mg daily Flovent 220 two puffs [Hospital1 ] folic acid 1 mg daily FeSO4 325 mg [Hospital1 ] Lanoxin 0.125 mg daily Lasix 20 mg daily Nifedipine XL 60 mg daily prilosec 20 mg daily spiriva 18 mcg daily ? MVI zocor 40 mg daily Guaifenisin prn alleve prn fexofenidine 180mg prn loratadine 10mg qdaily colace prn simvastatin 40 qdaily Discharge Medications: No insulin needed on d/c. Discharge Disposition: Home With Service Facility: VNA Assoc. of [Hospital3 ] Discharge Diagnosis: Congestive Heart Failure COPD No diabetes (steroid induced hyperglycemia) Discharge Condition: Stable Discharge Instructions: You were treated for and exacerbation for COPD and congestive heart failure. Continue your medications as outlined here. Follow-up with your primary care physician at [Name9 (PRE) 1562] Hospital within 1 week. Followup Instructions: Follow up with your primary care physician within one week of discharge.	[ "790.29", "E932.0", "272.4", "491.21", "305.1", "428.0", "414.8", "518.81", "486", "585.9", "427.31", "441.2", "403.90" ]	icd9cm	[ [ [] ] ]	[ "33.24", "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]	7317, 7378	4337, 6852	337, 349	7495, 7504	2852, 2852	7767, 7843	2350, 2368		7267, 7294		7399, 7474		6878, 7244			7528, 7744									2383, 2833																								278, 299										377, 1869							2868, 4314								1891, 2194	2210, 2334
51,836	141,307	52073	Discharge summary	report	Admission Date: [2171-10-19] Discharge Date: [2171-10-29] Date of Birth: [2094-8-17] Sex: F Service: MEDICINE Allergies: Niacin Preparations Attending:[First Name3 (LF) 832] Chief Complaint: melena Major Surgical or Invasive Procedure: esophagoduodenoscopy [10-19] esophagoduodenoscopy [10-22] PRBC transfusions History of Present Illness: 77 y/o woman with GIB who is transferred to us from MICU. Has history of AVR/MVR on coumadine who prior to this admission was put on lovenox bridge back to coumadin after recent eye surgery and presented with fatigue and meleena on [10-19]. . She does not have prior history of GI symptoms or bleeding. She did not have recent weightloss or systemic symptoms. She was not on aspirin and did not report NSAID use. . 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, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. . Past Medical History: 1. Severe mitral stenosis. 2. Mitral insufficiency. 3. Aortic regurgitation. 4. Aortic stenosis. 5. Rheumatic heart disease. 6. History of atrial fibrillation. 7. Diabetes mellitus. 8. Chronic renal failure. 9. s/p aortic, mitral bivalve replacement. 10. s/p hysterectomy for uterine fibroids. 11. s/p CABG Social History: Husband died from MI [80] years ago. Strong family support with sons and daughter in the area. - Tobacco: none - Alcohol: none - Illicits: none Family History: DM in parents, brothers, no CAD Physical Exam: Vital signs 99,5 141/57 84 99% General: NAD HEENT: Sclera anicteric, MMM, oropharynx clear Lungs: CTA CV: Prominent S1 + S2, no m/r/g Abdomen: soft, NTND, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Pertinent Results: [2171-10-18] 11:20PM BLOOD WBC-11.0# RBC-1.88# Hgb-6.2# Hct-18.0# MCV-96# MCH-32.9# MCHC-34.5 RDW-16.8* Plt Ct-195 [2171-10-18] 11:20PM BLOOD Neuts-68.8 Lymphs-26.5 Monos-3.9 Eos-0.4 Baso-0.4 [2171-10-18] 11:20PM BLOOD PT-22.3* PTT-42.7* INR(PT)-2.1* [2171-10-18] 11:20PM BLOOD Glucose-346* UreaN-106* Creat-2.2* Na-134 K-4.3 Cl-103 HCO3-18* AnGap-17 [2171-10-20] 09:15AM BLOOD Calcium-9.8 Phos-2.7 Mg-1.7 [2171-10-29] 06:20AM BLOOD WBC-4.1 RBC-2.71* Hgb-8.1* Hct-24.4* MCV-90 MCH-30.0 MCHC-33.3 RDW-16.1* Plt Ct-232 . Discharge labs: . [2171-10-29] 09:00AM BLOOD PT-27.1* PTT-64.8* INR(PT)-2.6* [2171-10-29] 06:20AM BLOOD Glucose-97 UreaN-12 Creat-1.2* Na-141 K-4.2 Cl-114* HCO3-20* AnGap-11 [2171-10-29] 06:20AM BLOOD Calcium-10.2 Phos-2.6* Mg-2.0 . Microbiology: [2171-10-24] BLOOD CULTURE Blood Culture: neg [2171-10-24] BLOOD CULTURE:neg [2171-10-20] SEROLOGY/BLOOD HELICOBACTER PYLORI ANTIBODY TEST- neg [2171-10-19] URINE CULTURE- neg . ECG [10-18] Sinus rhythm. Prolonged P-R interval. Inferior and lateral ST-T wave changes are likely due to left ventricular hypertrophy with repolarization abnormality, although cannot exclude myocardial ischemia. [10-26] Atrial fibrillation with rapid ventricular response. Non-specific ST-T wave changes. Low voltages in the limb leads. Compared to the previous tracing the atrial fibrillation is new. . CXR [2171-10-24]: Small right greater than left pleural effusions are new. Otherwise, the lungs are clear without focal opacity. The heart is top normal in size with normal cardiomediastinal silhouette. Status post aortic and mitral valve replacement with sternotomy wires seen. There is calcification of the aortic arch. Brief Hospital Course: 77F on Coumadin for AVR/MVR who developed melena and fatigue while on Lovenox bridge to Coumadin after recent eye surgery and was found to have severe anemia and bleeding esophageal ulcer. . # UGIB: Presented with melena and fatigue while on Lovenox bridge to Coumadin after recent eye surgery. Found to have anemia (see below) which was treated with multiple PRBC transfusions. In ED NG lavage was positive and did not clear, She was put on IV Protonix, got PRBC X 3 and transferred to the ICU. Anticoagulation was continued throughout her hospital course for mechanical AVR/MVR. Had EGD [10-19] which showed distal esophageal ulcer with visible bleeding vessel on a Schatzki's ring which was clipped. H. pylori serology - negative. Did not have history suggestive of NSAID ulcers or pill esophagitis. Transferred to the medicine floor [10-20] for continued care where she continued to have melanous stool and down trending Hct. Re-scoped [10-22] with oozing from the same site treated with epinephrin and blind-clipping X5 as could not visualize vessel. Subsequently on IV Protonix drip had stable Hct and resolution of melena. Discharged with PO Protonix 40mg [Hospital1 ] for 8 weeks. Will likely need second look endoscopy with biopsies. . # Anemia: Admitted with symptomatic normocytic anemia Hct 18 secondary to UGIB. Required several PRBC transfusions throughout her stay. Last Hct on morning of discharge was 24.4 following which she received another unit of PRBC. She will require close Hct follow up in the out-patient setting. . # Valvular Heart Disease s/p Valve replacements with Mechanical Aortic and Mitral Valves. Last echocardiography demonstrated normal cardiac valve and cavity function and size and mild PHTN. Was on IV heparin [Last Name (un) ] throughout her admission and finally bridged back to Warfarin. Discharged on Warfarin 3mg daily. INR at discharge = 2.6. Will continue INR monitoring with PCP. . # Atrial Fibrillation: history of Paroxysmal AF. At home was on Coumadin for stroke prevention and rate controlled with Diltiazem XL 240mg daily. Diltiazem was initially held due to risk of cardiac decompensation in the setting of acute blood loss. On [10-24] she had one episode of asymptomatic AF with RVR which spontaneously converted to sinus. Diltiazem was subsequently restarted. She was discharged on her home dose of Diltiazem 240 XL. Bystolic was held on admission and continues to be held at discharge as seems to be well rate and BP controlled. . # Fever: [10-23] single spike of fever to 101.1 which did not reccur. Infectious workup including UA neg and CXR were non revealing for infectious source. Blood cultures were negative. Fever quickly resolved no Abx were administered. . # Acute on Chronic renal failure: Admitted with Cr 1.7 with unkown baseline. Likely pre-renal failure [1-15] to hypovolemia from acute blood loss. Downtrended with IVF and PRBC to 1.2 which is probably her baseline. Will continued renal function monitoring in the outpatient setting. . # Thrombocytopenia: developed thrombocytopenia to 101 likely due to consumption in the setting of acute UGIB as well as dilution from repeated PRBC transfusion. This was resolved at discharge. . # Diabetes Mellitus: Stable. Home hypoglycemics were held on admission and she was treated with Insulin fixed dose + ISS. Discharged on Home regimen of oral hypoglycemics + Lantus insulin. . # Bil Pulmonary effusions: found incidentally on CXR [10-24]. Etiology unclear, possibly [1-15] to some cardiac decompensation in the setting of anemia. Will need repeat CXR in 6 weeks. Medications on Admission: Lovenox 40 mg [Hospital1 ] Coumadin, as directed diltiazem SR 240 mg Cap Oral daily Bystolic 10 mg Tab Oral 1 Tab daily Furosemide 20 mg Tab Oral [12-15] tablet 3/week Lipitor 80 mg Tab Oral 1 PO daily Zetia (ezetimibe) 10 mg Tab Oral 1 tab daily allopurinol 100mg QD glipizide 5 mg Tab Oral 1 PO BID Lantus 5U QHS Januvia 25 mg Tab Oral 1 PO daily acarbose 100 mg Tab Oral, 1 tab TID Synthroid 75mcg QD Vitamin D 1000mg QD calcium acetate 667 mg Cap Oral 1 daily ferrous sulfate 325 mg (65 mg Iron) 1 tab PO daily Klor-Con M20 20 mEq tab 1 SR tablet daily prednisolone acetate 1% Eye gtt susp opth TID left eye ketorolac 0.4 % Eye Drops Ophthalmic 1 Drops(s) TID left eye . Allergies: Niacin Preparations . Discharge Medications: 1. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic TID (3 times a day). 2. ketorolac 0.4 % Drops Sig: One (1) drop Ophthalmic TID (3 times a day). 3. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 4. diltiazem HCl 240 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 5. furosemide 20 mg Tablet Sig: 0.5 Tablet PO three times a week. 6. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day. 7. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO once a day. 8. glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 9. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 11. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO once a day. 12. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 13. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:120 Tablet(s) Refills:0 14. Lantus 100 unit/mL Cartridge Sig: Five (5) units Subcutaneous once a day. 15. acarbose 100 mg Tablet Sig: One (1) Tablet PO three times a day. 16. Januvia 25 mg Tablet Sig: One (1) Tablet PO once a day. 17. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day) for 50 days. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:1 18. Klor-Con M20 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 19. allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: upper GI bleeding esophageal ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted due to bleeding from your stomach. You had an endoscopy procedure which found bleeding from an ulcer in your esophagus. The bleeding was initially controlled during this procedure but it later had to be repeated due to re-bleeding. You have since been stable with no evidence of recurrent bleeding. You also received repeated blood transfusion to replace your losses. Throughout your hospital course treatment with IV heparin was continued to prevent stroke from your mechanical heart valves. You were finally observed while this treatment was transitioned to coumadin. As was explained to you while blood thining medication like coumadin may increase your risk of re-bleeding, it is felt that this treatment is required due to the risk and possible consequences of stroke in the absence of blood thinning treatment. . The following changes were made to your medications: . # Lovenox has been stopped. . # Bystolic has been held. Please consult your PCP about restarting this medication. . # Warfarin 1mg tablet, please take 3 tablets once daily. You should have your INR checked on Thursday and consult your PCP on further dosing. . # Pantoprazol 40mg tablet was added. Please take 1 tablet twice daily to help healing your ulcer and prevent re-bleeding. . # Sucralfate 1 gram Tablet. Please take 1 tablet 4 times daily to help protect your stomach linning. . Please be aware that some over-the-counter medications and supplements may increase risk of bleeding from your stomach and/or interfere with warfarin. Do not take any medication or other supplement withour consulting your doctor. Followup Instructions: Please keep the following appointments: . Name: [Last Name (LF) 7726],[First Name3 (LF) 177] A. Address: [Street Address(2) 7727],2ND FL, [Location (un) ],[Numeric Identifier 809] Phone: [Telephone/Fax (1) 7728] Appointment: Thursday, [10-31] at 12:00PM Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [2171-11-27] at 1 PM With: [Initials (NamePattern4) ] [Last Name (NamePattern4) 11716] [Name8 (MD) 11717], MD [Telephone/Fax (1) 463] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage Completed by:[2171-10-31]	[ "530.21", "530.3", "V45.69", "511.9", "416.8", "553.3", "V45.81", "276.52", "250.02", "403.90", "287.5", "285.1", "V45.89", "585.4", "244.9", "584.9", "V58.61", "427.31", "V43.3" ]	icd9cm	[ [ [] ] ]	[ "42.33" ]	icd9pcs	[ [ [] ] ]	9895, 9901	3917, 7541	288, 374	9980, 9980	2150, 2697	11765, 12464	1782, 1815		8307, 9872		9922, 9959		7567, 8284			10131, 11742		2713, 3894							1831, 2131																			841, 1266					242, 250										402, 822											9995, 10107				1288, 1597	1613, 1766
19,484	117,703	21448	Discharge summary	report	Admission Date: [2139-9-6] Discharge Date: [2139-9-11] Date of Birth: [2091-9-20] Sex: M Service: MED Allergies: Penicillins Attending:[First Name3 (LF) 287] Chief Complaint: Unresponsive Major Surgical or Invasive Procedure: Intubation History of Present Illness: 47 yo man with hepC, alcoholism, bipolar, here with unresponsiveness and alcohol level of 450, likely alcohol intoxication. also noticed to have lipase>1500, concern for acute alcohol pancreatitis. intubated in ed for airway protection. Past Medical History: alcohol withdrawal seizure, alcohol intoxication, alcohol pancreatitis, hepc, Bipolar d/o Social History: separated, homeless, frequent admission for alcohol intoxication Family History: NC Physical Exam: Admission VS:98.6/ 112/53,74,14,100% AC 650/14 PEEP 5, FiO2 60% INtubated + EtOH PERRLA, EMOI, non icteric RR no MRG CTA B Soft, +BS, No HSM no c/c/e Neuro: no withdrawl to Voice/Pain: Limited ewxam due to sedation. + Dolls Eyes Pertinent Results: [2139-9-6] 07:59PM COMMENTS-GREEN TOP [2139-9-6] 07:59PM O2 SAT-98 CARBOXYHB-1 MET HGB-1 [2139-9-6] 06:56PM ALT(SGPT)-172* AST(SGOT)-102* LD(LDH)-269* ALK PHOS-69 AMYLASE-439* TOT BILI-0.4 [2139-9-6] 06:56PM LIPASE-1546* [2139-9-6] 06:56PM ALBUMIN-3.8 CALCIUM-7.7* PHOSPHATE-2.9 MAGNESIUM-1.9 [2139-9-6] 06:56PM OSMOLAL-411* [2139-9-6] 06:56PM TSH-1.4 [2139-9-6] 06:56PM FREE T4-1.1 [2139-9-6] 06:56PM ASA-NEG ETHANOL-450* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2139-9-6] 06:34PM TYPE-[Last Name (un) ] TEMP-37.0 RATES-/14 TIDAL VOL-665 PO2-108* PCO2-47* PH-7.30* TOTAL CO2-24 BASE XS--3 -ASSIST/CON INTUBATED-INTUBATED COMMENTS-[Last Name (un) ] [Doctor First Name ] [2139-9-6] 05:33PM TYPE-ART PO2-460* PCO2-43 PH-7.34* TOTAL CO2-24 BASE XS--2 INTUBATED-INTUBATED [2139-9-6] 05:30PM CK(CPK)-945* [2139-9-6] 05:30PM cTropnT-<0.01 [2139-9-6] 05:30PM CK-MB-9 [2139-9-6] 04:43PM LACTATE-5.7* [2139-9-6] 03:37PM URINE HOURS-RANDOM [2139-9-6] 03:37PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2139-9-6] 03:37PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.020 [2139-9-6] 03:37PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2139-9-6] 03:37PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 [2139-9-6] 03:27PM GLUCOSE-87 LACTATE-6.3* NA+-141 K+-4.0 CL--99* TCO2-23 [2139-9-6] 03:15PM UREA N-11 CREAT-0.9 [2139-9-6] 03:15PM AMYLASE-102* [2139-9-6] 03:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2139-9-6] 03:15PM WBC-9.6 RBC-4.16* HGB-13.2* HCT-38.4* MCV-92 MCH-31.8 MCHC-34.4 RDW-13.4 [2139-9-6] 03:15PM PLT COUNT-204 [2139-9-6] 03:15PM PT-13.2 PTT-24.8 INR(PT)-1.1 [2139-9-6] 03:15PM FIBRINOGE-257 Brief Hospital Course: 1. Decreased mental status: Thought secondary to etoh intoxication w/ repeat etoh level greater than 400. Head CT was neg, no evidence of infection. Tox o/w neg. Extubated on hospital day 1 and mental status slowly improved during remainder of hosptial course. 2. Psych: Further history from pt following extubation reveals h/o bipolar dz on lithium, zypreza and Celexa. Attempted to arrange psych f/u with [Hospital1 1474] VA. Per their records, Patient has not shown for multiple appointments and thus must go directly to Building 3 in order to get back into the day program. 3. EtOH abuse: Empirically started on iv valium q6 during hospital day 1 and 2. Pt reports h/o etoh withdrawal but no frank seizures. Following hospital day 2, switched to valium prn for ciwa greater than 10 - has not required additional valium. Was seen by social work and has been offered inpt detox vs shelter with EtOH outpatient services. 4. Hepatitis: Known HCV and also etoh abuse. Mild elevation of transaminase but u/s without frank cirrhosis no evodence of HCC. Has been continued on thiamine, folate and protonix. Will need outpt liver f/u. 5. Pancreatitis: Presumed secondary to etoh and initial abdominal u/s neg for structural damage. Amylase/lipase improved during hospital course w/ ivf and pt reporting decreased abdominal pain and beginning to take po's. Has been advised against etoh and will require inpt detox as above. 6. Elevated CPK: unclear etiology but neg mb fraction and troponin. Thought secondary to mild rhabdo/?pancreatitis and has trended down during hospital course and normalized at time of discharge. Medications on Admission: None Discharge Medications: 1. Lithium Carbonate 450 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). Disp:30 Tablet Sustained Release(s) Refills:0 2. Lithium Carbonate 450 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO QPM (once a day (in the evening)). Disp:60 Tablet Sustained Release(s) Refills:0 3. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:0 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:0 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:0 7. Olanzapine 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home with Service Discharge Diagnosis: EtOH abuse EtOH intoxication Resp. Distress Hepatitis C Virus Alcohol Pancreatitis. Bipolar disorder Discharge Condition: To shelter in stable condition Discharge Instructions: Please continue to take all your medications as directed. It is important that you follow up with Alcohol treatment, as planned by the socail worker. If you have any recurrence of your prior symptoms, please go to the neariest emergency room. If you have any throughts of hurting your self, call or got the nearest emergency room. Followup Instructions: We have a planned follow up appointment with the [Hospital1 1474] VA. [Location (un) 470]. Please bring a copy of your discharge Summary to this appointment. Primary Care Medical Services: Building 3. [2146-9-15]:00am. At the appointment, please go to the psychiatry clinic to arrange a reevaluation. This is also on the [Location (un) ]. [Telephone/Fax (1) 56637], ext: 2287 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 288] MD, [MD Number(3) 289]	[ "303.01", "070.54", "V60.0", "296.7", "577.0" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]	5615, 5634	3009, 3022	278, 291	5779, 5811	1041, 2986	6191, 6720	772, 776		4690, 5592		5655, 5758		4661, 4667			5835, 6168									791, 1022																								226, 240										319, 560											3037, 4635				582, 674	690, 756
10,110	113,401	7419	Discharge summary	report	Admission Date: [2201-3-27] Discharge Date: [2201-4-1] Date of Birth: [2137-3-4] Sex: M Service: CARDIOTHORACIC Allergies: Byetta Attending:[First Name3 (LF) 922] Chief Complaint: 64 yoM with known CAD complained of progressive angina, referred for cardiac catheterization Major Surgical or Invasive Procedure: CABG [3-28] Cardiac catheterization [3-27] History of Present Illness: 64yo man with history of HTN,^chol,DM, and known CAD s/p PCI of Cx(87) and RCA(99) free of angina after PCI know with recurrent angina at rest and with minimal exertion for last several weeks. EF by echo 60% Past Medical History: CAD s/p PCI(Cx and RCA), HTN, ^chol, DM2, BPH, Colon CA s/p colonoscopy and chemo, Tonsillectomy, Depression Social History: Divorced, lives with friend. Owns [Name2 (NI) 27234] shop. Occaisional ETOH, denies tobacco use Family History: non contributory Physical Exam: Admission: VS T 98 HR 66 BP 113/60 RR 14 O2sat Ht 5'7" Wt 165 lbs Gen NAd Neuro A&Ox3, nonfocal exam Chest CTA-bilat, well healed Porta-cath site Rt chest wall CV RRR no M/R/G Abdm soft, NT/ND/NABS Ext warm, well perfused. No edema. No varicosities Discharge Pertinent Results: [2201-3-27] 11:30AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.000* [2201-3-27] 09:00AM GLUCOSE-137* UREA N-21* CREAT-0.9 SODIUM-136 POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-26 ANION GAP-11 [2201-3-27] 09:00AM ALT(SGPT)-22 AST(SGOT)-20 CK(CPK)-172 ALK PHOS-67 AMYLASE-72 TOT BILI-1.9* DIR BILI-0.3 INDIR BIL-1.6 [2201-3-27] 09:00AM ALBUMIN-4.1 CALCIUM-9.1 CHOLEST-139 [2201-3-27] 09:00AM %HbA1c-7.4* [Hgb]-DONE [A1c]-DONE [2201-3-27] 09:00AM WBC-7.3 RBC-4.08* HGB-12.3# HCT-34.5 MCV-85 MCH-30.1 MCHC-35.6* RDW-14.8 [2201-3-27] 09:00AM PT-11.5 PTT-26.4 INR(PT)-1.0 C.CATH Study Date of [2201-3-27]: 1. Selective coronary angiography of this right dominant system demonstrated a three vessel CAD. The LAD and LCx had a common ostium. The LAD had a long proximal ulcerated lesion up to 90%. The LCx had a 70% proximal stenosis and diffuse disease elsewhere. The RCA had a 70% ostial stenosis; previously placed stent was patent. 2. Resting hemodynamics revealed a slightly elevated left sided filling pressure with an LVEDP of 15 mm Hg. 3. Left ventriclulography revealed no mitral regurgitation. The LVEF was preserved and was calculated to be 60% with a normal wall motion. CXR [2201-3-30]: S/P CABG. Heart size is within normal limits. There are small bilateral pleural effusions, left greater than right, with linear atelectases in the left lower lobe. No pneumothorax. ECHO Study Date of [2201-3-28]: PRE-BYPASS: The left atrium is normal in size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3)appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Torn mitral chordae are present. Mild (1+)mitral regurgitation is seen. There is no pericardial effusion. POST CPB: Preserved biventricular systolic function. No change in valve structuer or function. Brief Hospital Course: Pt with progressive angina referred for cardiac catheterization which revealed native 3 vessel disease. Following catheterization patient was referred to CT surgery for consideration for CABG. Pt accepted for CABG and on [3-28] pt was brought to operating room where he had CABGx4. Please see OR report for details, in summary pt had LIMA-LAD, SVG-Diag, SVG-OM, SVG-RCA. His bypass time was 120 minutes with X-clamp time of 102 min. He did well in the immediate post-op period and was extubated on the day of surgery. On POD1 he was transferred to the step down floor. The remainder of his postop course was uneventful. On POD2 his chest tubes were removed and physical therapy was started. On POD3 his temporary pacing wires were removed. PT continued to work with the patient until on POD4, he was discharged home with VNA. Medications on Admission: ASA 81', Toprol XL 50", Lipitor 40', Altace 10', Lantus 17 QHS, MVI, Coenzyme Q10 Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q 3-4 hrs as needed. Disp:50 Tablet(s) Refills:0 5. Insulin Glargine 100 unit/mL Solution Sig: Seventeen (17) units Subcutaneous at bedtime. Disp:1 bottle Refills:0 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [Hospital1 ] x5 days then 400mg QD x 7 days then 200mg QD. Disp:70 Tablet(s) Refills:0 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 8. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24HR(s) Refills:0 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:14 Tablet(s) Refills:0 10. 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 Discharge Disposition: Home With Service Facility: VNA Assoc. of [Hospital3 ] Discharge Diagnosis: CAD s/p CABGx4(LIMA-LAD, SVG-Diag, SVG-OM, SVG-RCA)[3-28] PMH: CAD, Depression, HTN, ^chol, DM2, BPH, Colaon CA s/p colectomy/chemo, tonsillectomy 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: [Hospital 409] clinic inn 2 weeks Dr [Last Name (STitle) ] in [3-21] weeks Dr [Last Name (STitle) 914] in 4 weeks Follow up with urologist Completed by:[2201-4-1]	[ "401.9", "250.00", "V10.05", "414.01", "272.0", "600.00", "411.1" ]	icd9cm	[ [ [] ] ]	[ "36.13", "88.55", "39.61", "88.53", "99.04", "37.22", "36.15" ]	icd9pcs	[ [ [] ] ]	5914, 5975	3594, 4426	363, 415	6169, 6175	1235, 3571	6376, 6560	917, 935		4558, 5891		5996, 6148		4452, 4535			6199, 6353									950, 1216																								231, 325										443, 652															674, 784	800, 901
70,754	116,929	49684	Discharge summary	report	Admission Date: [2147-7-4] Discharge Date: [2147-8-23] Date of Birth: [2103-7-19] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 4377] Chief Complaint: Left lower leg swelling Major Surgical or Invasive Procedure: hemodialysis left internal jugular hemodialysis catheter placement and removal right upper extremity PICC placement chemotherapy: 1st cycle fludarabine (50% dose due to renal function), 2nd cycle CHOP R Nephrosotomy and L renal stent placement R Nephrostomy and L stent removal History of Present Illness: 43 y.o women with a history of hepatitis C, recent lymph node biopsy on [2147-6-9] at [Hospital3 ] hospital who presents today with left lower extremity redness and pain, who was then found to have severe hyperkalemia and acute renal failure. The patient recently was admitted to [Hospital3 417] hospital from [2147-6-9] to [2147-6-13] for an elective excisional biopsy of diffuse lymphadenopathy, most prominent in her left groin. Based on limited records, her creatinine was 0.9 at that time. She was then discharged from the hospital to a [Hospital1 1501] due to inability to ambulate, where she has been residing ever since. Today, at the [Hospital1 1501] her labs were checked and she was found to have a K of 7.8 and a creatinine of 9.9. The patient herself reports that she feels that her urine output has been decreasing lately along with some increased generalized edema. In the ED, initial VS were: 98.9 92 146/90 18 95% RA. On labs, her K was 8.6 and her creatinine was 10.6. She was given 10U of regular insulin and 1 amp of D50W for her hyperkalemia. She was also given a dose of vancomycin for a possible cellulitis. A left lower extremity ultrasound was negative for clot. Other notable labs include a uric acid level of 10.1 and a phosphate of 6.7. Nephrology was consulted and recommended that she be admitted to the MICU for medical management of her hyperkalemia. Her K after the above interventions dropped to 6.3, and given an EKG that did not show evidence of cardiac toxicity, dialysis was not initiated. On arrival to the MICU, patient's VS were 97.4 79 118/82 15 98% on RA Past Medical History: Hepatitis C hypertension Anxiety Depression myocardial infarction Bilateral lower extremity edema Irritable bowel syndrome Hemorrhoids Heroin abuse Borderline personality disorder Social History: IVDA, quit years ago according to patient, during a search of her belongings a significant amount of drug paraphenelia was found including a spoon, wrapping papers, and syringes. Current 1ppd smoker. No EtOH. Family History: NC Physical Exam: ADMISSION EXAM: General: somlenent, no acute distress HEENT: Sclera anicteric, dry mucous membranes, PERRL Neck: supple, JVP not elevated, mild left anterior cervical lymphadenoapthy CV: Regular rate and rhythm, normal S1 + S2, mild [3-20] mid systolic murmur best heard at RUSB. Lungs: Bibasilar crackles, R>L Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding. Dressing at inguinal site c/d/i. Significant bilateral inguinal lymphadenopathy. GU: foley in place Ext: Warm, well perfused, 2+ pulses, significant bilateral LE edema Neuro: GCS 14, oriented x3, moving all 4 extremities, otherwise unable to cooperate with neuro exam. DISCHARGE EXAM: General: alert, no acute distress HEENT: Sclera anicteric, dry mucous membranes, PERRL Neck: supple, JVP not elevated CV: Regular rate and rhythm, normal S1 + S2, no MRG Lungs: CTAB Abdomen: soft, slightly distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding. GU: nephrostomy stent and Ext: Warm, well perfused, 2+ pulses, 1+ bilateral LE edema Neuro: alert and oriented x3, CN II-XII grossly intact, normal gait, normal muscle tone and buk Pertinent Results: ADMISSION LABS: [2147-7-4] 09:25PM BLOOD WBC-3.9* RBC-3.50* Hgb-9.4* Hct-30.2* MCV-86 MCH-26.9* MCHC-31.2 RDW-13.0 Plt Ct-266 [2147-7-4] 09:25PM BLOOD Neuts-66.6 Lymphs-23.2 Monos-8.5 Eos-1.5 Baso-0.1 [2147-7-4] 09:25PM BLOOD PT-10.0 PTT-30.9 INR(PT)-0.9 [2147-7-5] 03:02AM BLOOD Ret Aut-1.2 [2147-7-4] 09:25PM BLOOD Glucose-80 UreaN-70* Creat-10.6* Na-135 K-8.6* Cl-98 HCO3-22 AnGap-24* [2147-7-4] 09:25PM BLOOD CK(CPK)-169 [2147-7-4] 09:25PM BLOOD Calcium-9.0 Phos-6.7* Mg-3.2* UricAcd-10.1* [2147-7-5] 07:01AM BLOOD calTIBC-247* VitB12-578 Ferritn-200* TRF-190* [2147-7-5] 03:02AM BLOOD Osmolal-305 [2147-7-5] 03:02AM BLOOD Valproa-47* [2147-7-4] 09:25PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2147-7-4] 09:49PM BLOOD Lactate-1.2 URINE: [2147-7-5] 12:25AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.004 [2147-7-5] 12:25AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-MOD [2147-7-5] 12:25AM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-1 TransE-<1 [2147-7-5] 12:25AM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG STUDIES: [2147-7-4] Lower extremity ultrasound: No DVT of the left lower extremity. [2147-7-4] CXR: 1. Retrocardiac opacity compatible with pneumonia or atelectasis 2. Prominence of the right hilus may be secondary to low lung volumes or hilar opacity. Suggest follow up radiographs, ideally with better inspiration. [2147-7-5] CXR: 1. Left IJ catheter in the mid SVC. 2. Mild pulmonary edema. [2147-7-6] 3:26 PM # [Telephone/Fax (1) 103896] CT CHEST, ABD & PELVIS W/O CON 1. Infiltrative soft tissue mass surrounding the retroperitoneal region, including the aorta, IVC, and presumably the ureters. This is likely secondary to lymphoma and would be expected to be the cause of the patient's bilateral renal obstruction. However, given the cortical thinning on the left, this is likely a chronic process. 2. Ground-glass opacities seen within the right upper lobe and right middle lobe suggestive of atypical infection. The typical consolidations seen with bacterial pneumonia are not evident on this examination. 3. Bilateral pleural effusions are moderate in size, slightly greater on the right and on the left, with associated atelectasis. [2147-7-12] 12:20 PM # [Numeric Identifier 103897] INTRO CATH RENAL 1. Successful uncomplicated placement of a left-sided 8 French x22 cm nephroureteral stent. 2. Successful uncomplicated placement of an 8 French nephrostomy tube in the right kidney. 3. A future study is recommended in [3-17] weeks to try to attempt reconversion of the right-sided nephrostomy tube to a nephroureteral stent and to try to further characterize the filling defect seen in the right renal pelvis, which could be an air bubble. [2147-7-18] 11:23 AM # [Telephone/Fax (1) 103898] RENAL U.S. IMPRESSION: Complete resolution of left hydronephrosis. Near-complete resolution of right hydronephrosis with only minimal residual hydronephrosis noted. [2147-7-19] Cardiovascular ECHO The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. IMPRESSION: Mild aortic regurgitation with normal valve morphology. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. If clinically indicated, a transesophageal echocardiographic examination is recommended to assess aortic valve morphology. CLINICAL IMPLICATIONS: Based on [2142] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. [2147-7-19] Radiology MRI PELVIS W/O & W/CONT 1. 3.6-cm lymph node in the left external iliac chain has features concerning for a necrotic lymph node with probable secondary infection (suppurative lymph node). An 1.8-cm lymph in the left common iliac chain has similar characteristics, and also is concerning for a suppurative lymph node. 2. Edema and swelling of the left iliacus and obturator internus muscles is suggesting of an ongoing inflammatory or infectious process. 3. Compression of the left external iliac artery and vein due to the enlarged external iliac chain lymph node without evidence of thrombus or occlusion. 4. Extensive pelvic and inguinal lymphadenopathy. [2147-7-21] Radiology US UPPER EXTREMITY, SOFT TISSUE NODULE IMPRESSION: Multiple subcutaneous soft tissue nodules in the right and left upper extremity, suggestive of lymphomatous deposits/ lymph nodes in the soft tissues. If desired, these can be FNAed/biopsied under imaging guidance. [2147-7-24] Radiology MR THIGH W&W/O CONTRAST 1. Left inguinal lymphadenopathy, slightly progressed since the recent MRI one week ago. No new lesion identified, and no distal lymphadenopathy in the thigh. 2. Diffuse subcutaneous soft tissue swelling and edema is nonspecific but may represent lymphedema or cellulitis. Fluid tracks along the superficial fascia, but this is unlikely to represent fasciitis given the lack of fascial enhancement. Mild inter- and intramuscular edema representing mild myositis. 3. Diffuse patchy bone marrow signal abnormality likely represents red marrow, but osseous lymphomatous involvement is not excluded especially in the intertrochanteric regions bilaterally. [2147-7-25] Pathology Tissue: RIGHT ARM NODULE. Hematoma with early organization. No evidence of lymphoma. [2147-7-27] Radiology CT CHEST W/O CONTRAST IMPRESSION: No findings to suggest pulmonary infection with unchanged prominent lymph nodes as above. [2147-8-12] Abdomen and Pelvis IMPRESSION: 1. Decreased size of left retroperitoneal lymph node conglomerates and bilateral inguinal lymphadenopathy. 2. Right nephrostomy tube and left nephroureteral stent appropriately positioned with interval resolution of bilateral hydronephrosis. [2147-8-21] Antegradge nephrogram IMPRESSION: 1. Left antegrade nephrostogram demonstrated brisk passage of contrast through the left ureter into the urinary bladder. Mildly dilated left interpolar to lower pole calices, likely as a result of caliectasis. No left UPJ obstruction. Left NU stent was removed. 2. Right antegrade nephrostogram did not demonstrate hydroureteronephrosis. Brisk passage of contrast through the reter into the bladder. Right nephrostomy catheter was removed. ---------- MICRO: [2147-7-5] IMMUNOLOGY HCV VIRAL LOAD-FINAL - 23,720,478 IU/mL. [2147-7-8] IMMUNOLOGY HIV-1 Viral Load/Ultrasensitive-FINAL HIV-1 RNA is not detected. [2147-7-12] STOOL C. difficile DNA amplification assay-FINAL -NEGATIVE ---- [2147-7-19] 9:46 am STOOL CONSISTENCY: SOFT Source: Stool. FINAL REPORT [2147-7-21] C. difficile DNA amplification assay (Final [2147-7-19]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final [2147-7-21]): NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [2147-7-21]): NO CAMPYLOBACTER FOUND. Cryptosporidium/Giardia (DFA) (Final [2147-7-21]): NO CRYPTOSPORIDIUM OR GIARDIA SEEN. --- BLOOD CULTURES: 5/22,26,27 all negative. 6/4,5,6,7,8,9,13 all negative ----- ECG - [2147-7-31] Sinus rhythm. Precordial T wave inversions of uncertain significance. Since the previous tracing of [2147-7-28] ventricular premature beat is not seen, the lateral T waves are improved, early precordial T wave abnormalities persist. Intervals Axes Rate PR QRS QT/QTc P QRS T 82 144 86 [Telephone/Fax (2) 103899] 35 ------- Brief Hospital Course: 43 yoF with h/o hepatitis C, HTN, IV drug use, and recent diagnosis of follicular lymphoma who initially presented with acute obstructive renal failure (s/p HD and R nephrostomy and L nephroureteral stent) with course complicated by fevers and left necrotic iliac lymph nodes. # Follicular Lymphoma: Final pathology showed follicular lymphoma, follicular growth pattern, cytological grade 1 of 3. New subcutaneous nodules were concerning for lymphomatous transformation, supported by increasing LDH. Pt had an excisional biopsy of R upper extremity subcutaneous nodule by general surgery on [2147-7-25], but these only showed organizing hematoma, perhaps from prior drug use. Choices for treatment were initially limited by Pt's profound obstructive renal failure. Pt was treated with fludarabine D1-5, dose-reduced to 50% normal and completed 2 cycles of R-CHOP when renal function resolved. [2147-8-12] CT abdomen showed interval improvement in retroperitoneal masses and improvement of bilateral hydronephrosis. Pt was discharged with acyclovir, fluconazole, and bactrim ss for ppx. She has an appointment with Oncologist Dr [Last Name (STitle) 21628] (ph:1-[Telephone/Fax (1) 71494] fax: [Telephone/Fax (1) 83170] address [Last Name (NamePattern1) 103900]. [Hospital1 1474], Mass) on [9-11]. # Healthcare associated pneumonia: Patient presented with fever and infiltrate on CXR. Pt was treated with vancomycin and pip/tazo 4.5g iv q6h d1 = [7-10] for full 8 day course with complete resolution of symptoms and radiographic resolution on repeat CXR. # Acute renal failure/obstructive uropathy: Pt presented in profound obstructive renal failure with Cr 10.6 and potassium 8.6. Pt was initally admitted to ICU, initially medically managed, then dialyzed and transferred to BMT service for further managment. Pt had uneventful placement of R nephrostomy tube and L nephro-ureteral stent placed by IR on [2147-7-12]. Pt had little urine output from L nephro-ureteral stent (~250mL over 16 hrs) but plentiful urine output from R nephrostomy (~2.4L over 16 hrs). L nephro-ureteral stent was capped per IR on [2147-7-13]. Given rapid improvement in Cr, down to 2.5 on [2147-7-13] morning w/out dialysis, further decreasing to 2.0 on [2147-7-14], Pt's HD line was discontinued w/out issue. Pt's Cr continues to improve to 1.1 on [2147-7-24] and ultimately down to baseline. Repeat renal ultrasound showed complete resolution of L hydronephrosis and almost complete resolution of R hydronephrosis. R nephrostomy was capped on [2147-7-27], On [2147-8-21], pt had IR evaluate the nephrostomy tubes via nephrostogram which showed no obstruction of R or L ureter, the nephrostomy tube and stents were removed without complication. Patient with good UOP and creatinine of 1.1 at time of discharge # UTI. Patient with positive UA. Ucx + E.Coli. Patient placed on macrobid 100 mg twice per day with instruction to take thru [2147-9-7] # Hyperkalemia - Secondary to the acute renal failure, treated with Kayexalate, insulin, and calcium gluconate prior to initiation of HD. No e/o EKG changes. Resolved with HD. K at time of discharge 5.5 # Altered mental status. Noted on admission. Differential diagnosis: uremia, hypoglycemia (although she was quite sleepy prior to getting insulin in the emergency room), accumulation of drugs including klonopin and dilaudid that she had been receiving due to her renal failure. Resolved with HD and mentating at baseline. # Chronic back pain / abdominal pain with possible radiculopathy. Pt is an active cocaine and heroin user.With initial pain consult evaluation, Pt was placed on hydromorphone IV, PO, and methadone, gabapentin, and lidocaine patch. Pt was titrated to methadone 10mg po tid, hydromorphone to 4mg po q4hrs prn. QTc monitored and within normal limits. Pt was strongly opposed any effort to taper her pain medications but after pt was rejected by facilities for having a much too high daily dilaudid requirement, patient was willing to half her Dilaudid dose from 8mg to 4mg every 4 hours. Will need outpatient pain medication taper. # Anxiety / agitation: Very labile behavior with hypothesized underlying personality disorder per psych. Pt was started on divalproex 250 mg PO BID, olanzapine 5mg po tid standing per psychiatry; clonazepam 1 mg PO TID for anxiety and lorazepam 1mg po tid prn. These medications should be tapered as an outpatient. She will follow up with her primary care doctor after discharge. # Normocytic Anemia: Hct initially downtrending, hemolysis labs negative. Nadir of 21.1 on [2147-7-10]. Likely related to underproduction in setting of underlying lymphoma/renal failure. Iron studies suggestive of anemia of chronic disease. No evidence of bleeding. HCT 26.8 on discharge. # HCV: HCV viral load 23 million. Pt has not been exposed to HBV. Pt's LFT have been normal. She will need outpatient hepatology follow up for active hepatitis C. # Drug abuse - Patient with current IV drug use. Pt was also using drugs in while hospitalized. Social work was consulted. Will need outpatient support program. Patient will follow up with PCP and pain specialist. # Disposition issues: Pt was homeless prior to admission. Her husband is also at [Name (NI) 10246], and they had a significant altercation while at [Hospital1 18]. Patient has been barred from several shelters/rehabs due to issues with continued heroin abuse and altercations w/ other residents. Rejected by [Hospital1 10246], [Hospital ] hospital, [Doctor Last Name ] house. As patient did not meet inpatient criteria after lengthy discussion patient was discharged to live with a friend in [Name (NI) 5110], MA per her request. # Follow-up The patient will follow up with her PCP, [Name10 (NameIs) ] [Name (NI) 103901] (ph: [Telephone/Fax (1) 10216] fax:[Telephone/Fax (1) 103902] address:64 Main [Location (un) 103903] Mass)on [2147-8-28]. She will also meet with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 12967] for pain management. She will meet with Oncologist Dr [Last Name (STitle) 21628] in [Hospital1 1474] on [9-11], [2147]. TRANSITIONAL ISSUES: -needs continued chemotherapy for treatment of lymphoma -will need outpatient hepatology follow up for active hepatitis C -will need referral to drug abuse cessation program -taper pain medications -taper sedatives including lorazepam, clonazepam Medications on Admission: Dilaudid 2-4mg PO q3h prn pain. multivitamin 1 tab daily fluconazole 100mg daily depakote 250mg [Hospital1 ] ativan 0.5mg [Hospital1 ] prn kayexalate 30mg PO once on [7-4] klonopin 1mg tid colace 100mg [Hospital1 ] hydroxyzine 100mg qhs Discharge Medications: 1. Scalp prosthesis Scalp Prosthesis Dispense: 1 2. docusate sodium 100 mg capsule Sig: One (1) capsule 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. clonazepam 1 mg tablet Sig: One (1) tablet PO TID (3 times a day): anxiety. Disp:12 tablet(s) Refills:0 5. divalproex 250 mg tablet,delayed release (DR/EC) Sig: One (1) tablet,delayed release (DR/EC) PO BID (2 times a day). Disp:30 tablet,delayed release (DR/EC)(s) Refills:0 6. fluconazole 200 mg tablet Sig: One (1) tablet PO Q24H (every 24 hours). Disp:30 tablet(s) Refills:0 7. hydroxyzine HCl 25 mg tablet Sig: Four (4) tablet PO at bedtime as needed for pruritis. Disp:30 tablet(s) Refills:0 8. acyclovir 400 mg tablet Sig: One (1) tablet PO Q8H (every 8 hours). Disp:30 tablet(s) Refills:0 9. sulfamethoxazole-trimethoprim 400-80 mg tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 10. olanzapine 5 mg tablet Sig: One (1) tablet PO TID (3 times a day). Disp:15 tablet(s) Refills:0 11. lorazepam 0.5 mg tablet Sig: One (1) tablet PO twice a day as needed for anxiety. Disp:8 tablet(s) Refills:0 12. nitrofurantoin monohyd/m-cryst 100 mg capsule Sig: One (1) capsule PO Q12H (every 12 hours): End date [2147-9-7]. Disp:30 capsule(s) Refills:0 13. hydromorphone 4 mg tablet Sig: One (1) tablet PO every [5-19] hours as needed for pain. Disp:16 tablet(s) Refills:0 14. gabapentin 300 mg capsule Sig: One (1) capsule PO TID (3 times a day). Disp:30 capsule(s) Refills:0 15. allopurinol 100 mg tablet Sig: Two (2) tablet PO DAILY (Daily). Disp:30 tablet(s) Refills:0 16. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Transdermal once a day: Do not use with tobacco. If you are going to smoke, you must remove this patch due to risk of cardiovascular complications and death. Disp:4 4 Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: pneumonia hyperkalemia, now resolved obstructive renal failure, now resolved follicular lymphoma Secondary: hepatitis C heroin use chronic back pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [Known lastname ], You were admitted to the hospital because you had leg swelling and shortness of breath. You were found to have a large mass in your abdomen, later discovered to be follicular lymphoma, a type of cancer. This mass compressed both of your ureters and caused your kidneys to fail. When you arrived, you had dangerous high levels of potassium in your blood. You were treated with hemodialysis, and your condition stabilized. You then received a urinary stent in your left kidney and a nephrostomy in your right kidney. Your left kidney did not show much improvement in function, likely due to the chronic nature of the urinary obstruction. Your right kidney recovered very well. You were treated with chemotherapy, and you responded well to the initial two cycles. You were also treated for a pneumonia and had a full recovery. Your left leg and abdomen remain swollen, likely due to blockage of lymphatic drainage systems by your cancer. This should improve as your cancer responds to the chemotherapy. The kidney stent and kidney drain (nephrostomy) were removed and your kidney function has improved. Changes to your medications: To treat your pain, the following changes were made: Dilaudid 4 mg every 4-6 hours to treat pain Methadone will be dispensed at methadone clinic Gabapentin 300 mg three times per day Do not take these medications while driving or drinking alcohol or using recreational drugs as these will cause sedation and possible death if used in combination Please take stool softeners while taking narcotics because this can cause constipation For smoking cessation, please take: Nicotine patch 14 mg, replace once daily Do not take nicotine patch with cigarettes due to cardiovascular risk and possible death. To prevent infection, the following changes were made: fluconazole 200 mg daily acyclovir 400 mg every 8 hours bactrim single strength tablet daily To treat your urinary tract infection, macrobid 100 mg twice per day, please take through [2147-9-7] To treat your mood, continue on olanzapine 5 mg three times per day Please take all your other medications as prescribed. Followup Instructions: 1) [Hospital ] Clinic: 7 [Hospital Ward Name 1826] Outpatient Clinic @[Hospital1 18] Time: 12 pm (noon) tomorrow [8-24] 2) Dr. [Last Name (STitle) ] (PCP): Monday [8-28] 2:00 pm [Hospital1 1474] Neighborhood Health [Location (un) ] [Hospital1 1474], MA 3) [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 103904] (pain management): will see at [Hospital1 1474] Neighborhood Health 4) Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 21628] (oncologist): [9-11] [Hospital1 1474] Neighborhood Health phone [Telephone/Fax (1) 71494]	[ "251.2", "412", "401.9", "276.7", "305.60", "338.29", "785.0", "070.54", "729.5", "301.83", "V15.82", "301.9", "276.69", "996.1", "307.47", "307.9", "304.00", "599.0", "312.30", "041.49", "584.9", "591", "E947.8", "683", "693.0", "E879.8", "564.1", "780.60", "285.29", "E930.8", "780.97", "202.03", "300.4", "724.4", "486", "593.4" ]	icd9cm	[ [ [] ] ]	[ "55.03", "38.95", "87.75", "40.11", "97.61", "38.97", "39.95", "59.8", "99.25", "97.62" ]	icd9pcs	[ [ [] ] ]	21301, 21307	12568, 18800	335, 615	21510, 21510	3983, 3983	23833, 24452	2730, 2734		19373, 21278		21328, 21489		19095, 19350			21661, 22791									2749, 3458						3474, 3964	8244, 12545										18821, 19069	22820, 23810						272, 297										643, 2282							3999, 8221				21525, 21637				2304, 2485	2501, 2714
62,933	161,258	10420	Discharge summary	report	Admission Date: [2166-2-12] Discharge Date: [2166-2-16] Date of Birth: [2090-9-12] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 30] Chief Complaint: transferred from [Hospital1 3278]; initially presented for urinary retention and back pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 3443] is a 75 yo Cantonese-speaking man with h/o AFib, HTN, COPD and metastatic nasopharyngeal CA with known liver mets, who presented to [Hospital1 3278] for urinary retention and back pain. He is currently on Day 13 of cycle 2 of cisplatin and gencytabine. MRI of the spine showed no cord compression but lesions at C7, T10 and T12. He had 1.5L UOP with placement of the foley (per discharge summary, retention reportedly started in the evening of [2-9]). He did not receive morphine or compazine for pain [3-4] effects of urinary retention. history on the patient is limited due to language barrier (have not been able to contact interpreter yet). . He was a direct floor transfer. VS on arrival to the floor were 96.5, 112/70, 118 - 140 in Afib, 96% on RA. The patient was on his feet wlaking to the bathroom to urinate (though had a foley) when I met him. Past Medical History: 1. Hypertension 2. Atrial Fibrillation 3. Chronic obstructive pulmonary disease 4. Stage IV Nasopharyngeal Carcinoma - [2165-11-22] - rhinoscopy with tumor extending into the nasal cavity - [2165-12-3] PET-CT - FDG avid mass in nasopharynx, left palatine tonsils, clivus, floor of the sella turcica, posterior nasal cavity, posterior ethmoid air cells, and the sphenoid sinus; enlarged lymph nodes with associated necrosis; lytic bone lesion in right iliac bone - [2165-12-12] - Biopsy with squamous cell carcinoma 5. Poorly Characterized Hepatic Mass - It is unclear if this represents a metastatic lesion or a primary hepatic neoplasm; He is scheduled for a liver biopsy on [2165-12-30] 6. Obstructive sleep apnea 7. Hypophosphatemia 8. Hearing loss 9. Bilateral renal cysts (benign finding on recent CT abdomen) 10. Anemia 11. Arthritis Social History: Home: Cantonese-speaking; immigrated to the US from Southern [Country 651] approximately 12 years ago Tobacco: 80 PPY ( 2 PPD x 40 years), quit 10 years ago EtOH: Denies Drugs: Denies Occupation: Previously employed as a bus driver Family History: Father - died at about age 50 from an unknown cause to the patient. Mother - died in her 90s 4 siblings - 1 brother died of a cancer (unknown type) Physical Exam: VS on arrival to floor: 96.5, 112/70, 118 - 140 in Afib (100-120's at [Hospital1 3278] per d/c summary), 96% on RA GENERAL: was walking to bathroom with nurses when initially seen; pleasant small elderly Asian male HEENT: MMM, Op clear LUNGS: CTA thrughout CARDIO: irregularly irregular, rapid heart rate, could not distinguish any murmurs ABD: thin,, + BS, soft, NTND MS: no spinal tenderness EXTREMITIES: no edema SKIN: no rashes NEURO: AA, cannot ascertain orientation due to language barrier, was up walking to bathroom without difficulty, gait normal, strength seems to be symmetric and normal (does not cooperate for full neuro exam) Pertinent Results: [2166-2-12] 04:59AM BLOOD WBC-9.1 RBC-3.23* Hgb-10.1* Hct-30.4* MCV-94 MCH-31.2 MCHC-33.2 RDW-16.7* Plt Ct-184 [2166-2-14] 02:10AM BLOOD WBC-11.3# RBC-2.78 Hgb-8.8* Hct-26.1* MCV-94 MCH-31.5 MCHC-33.5 RDW-16.8* Plt Ct-110* [2166-2-15] 02:41PM BLOOD Hct-25.8* [2166-2-15] 05:42AM BLOOD PT-11.6 PTT-43.4* INR(PT)-1.0 [2166-2-12] 04:59AM BLOOD Glucose-148* UreaN-24* Creat-0.9 Na-134 K-3.5 Cl-96 HCO3-27 AnGap-15 [2166-2-15] 05:42AM BLOOD Glucose-104* UreaN-28* Creat-0.8 Na-140 K-3.3 Cl-101 HCO3-26 AnGap-16 [2166-2-12] 04:59AM BLOOD ALT-18 AST-19 CK(CPK)-29* AlkPhos-152* TotBili-1.2 [2166-2-12] 04:59AM BLOOD CK-MB-2 cTropnT-<0.01 [2166-2-15] 05:42AM BLOOD Calcium-8.5 Phos-2.3* Mg-1.4* [2166-2-12] 04:59AM BLOOD VitB12-566 [2166-2-12] 04:59AM BLOOD TSH-1.1 [2166-2-12] 03:21AM URINE RBC-50* WBC-1 Bacteri-NONE Yeast-NONE Epi-0 [2166-2-12] 03:21AM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR [2166-2-12] 03:21AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.015 [2166-2-12] 3:21 am URINE URINE CULTURE (Final [2166-2-14]): NO GROWTH. Blood Cultures - No growth to date CT HEAD [2166-2-12] - 1. No intracranial hemorrhage or major vascular territorial infarction identified. 2. Large soft tissue mass within the nasopharynx, with associated osseous destruction as detailed, which is incompletely imaged and characterized without IV contrast. If there is concern for intracranial metastases or an acute infarct, an MRI with gadolinium is recommended. MR/MRA BRAIN [2166-2-12] - 1. Acute/subacute left pontine infarct associated with high-grade stenosis of the basilar artery. 2. Large poorly-defined enhancing mass within the nasopharynx with permeation and destruction of the clivus with associated cervical adenopathy, better visualized on the recent neck MRI. 3. 3 mm right ophthalmic aneurysm. 4. Markedly irregular right posterior cerebral artery with high-grade segmental stenosis. VIDEO SWALLOW STUDY [2166-2-14] - Barium passed freely through the oropharynx and esophagus without evidence of obstruction. There was gross aspiration with multiple consistencies of barium including thin, nectar, and pudding. For details, please refer to the speech and swallow division note in the online medical record. Brief Hospital Course: #. URINARY RETENTION, NEW SPINAL METS: Patient was transferred for evaluation of urinary retention because all of his care is at [Hospital1 18]. He was transferred with foley in place with good output and no evidence of acute renal failure. There is concern for metastatic disease to spine given MRI findings at OSH prior to transfer, however there report with no sign of cord compression. Urine output was adequate with the foley and no evidence of renal failure on labwork. Urinary retention work-up was deferred pending the development of stroke and Afib with RVR. (see below) # ACUTE/SUBACUTE LEFT PONTINE INFARCT - Mr. [Known lastname 3443] developed right sided weakness and confusion shortly after arrival to [Hospital1 18]. CODE STROKE was initiated. Neurology consult felt that exam was extremely difficult to interpret in setting of no interpreter available, however was notable for confusion, disorientation vs. aphasia and weakness in RUE w/o signs of UMN disease at time of evaluation. NIHSS score was 8. CT HEAD was done due to patient's inability to lie flat for a prolonged period and showed no intracranial hemorrhage or major vascular territorial infarct identified. Patient underwent ROMI thich was negative, UA was negative for UTI. Started aspirin. Patient was transferred to MICU due Afib with RVR. Mr. [Known lastname 3443] then underwent MRI/MRA under sedation which showed acute/subacute left pontine infarct. He was started on heparin for anticoagulation. Mr. [Known lastname 3443] continued to be confused/disoriented after transfer from the Unit to the floor. Discussion with the family at that time about goals of care resulted in change of code status to DNR/DNI due to poor prognosis. Video swallow on [2166-2-14] showed aspiration with all levels of consistency. Family refused PEG. Ultimately, patient clinically deteriorated in setting of no PO intake, recent stroke with aspiration on video swallow, and afib with RVR requiring diltiazem infusion. He was likely aspirating his secretions. On [2166-2-16] a discussion regarding goals of care was again initiated and patient was placed on comfort measures only. Mr. [Known lastname 3443] passed away the evening of [2166-2-16]. # Atrial Fibrillation with RVR - Patient was noted to be in atrial fibrillation with rapid ventricular response after arrival from OSH. He was given IV Diltiazem for rate control without success. He was transferred to the MICU where he was placed on a continuous diltiazem infusion with rate control to the 90-100's. He was unable to take PO due to his CVA event on the night of admisison. He was then transferred to the cardiology floor on the diltiazem infusion for further management. He remained in atrial fibrillation throughout his hospital course. Patient's family refused PEG so he was continued on diltiazem infusion until goals of care were changed to comfort measures only. #. METASTATIC NASOPHARYNGEAL CA: Currently undergoing second round of palliative chemo prior to the admission. NG tube unable to be placed due to large nasopharyngeal mass. Patient's clinical course and prognosis was discussed with his primary oncologist. Medications on Admission: Diltiazem ER 120 mg QD-- last given on [2-11] at 11 am Advair 250/50 [Hospital1 ] Monteleukast 10 QD ProAir 90 Q6 hours Lidoderm patch QD Senna PEG Discharge Medications: Deceased Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased	[ "788.20", "197.7", "V66.7", "434.91", "293.0", "327.23", "198.5", "401.9", "716.90", "427.31", "147.9", "496" ]	icd9cm	[ [ [] ] ]	[ "96.04" ]	icd9pcs	[ [ [] ] ]	9170, 9179	5712, 8931	408, 414	9231, 9241	3323, 5689	9298, 9309	2494, 2643		9137, 9147		9200, 9210		8957, 9114			9265, 9275									2658, 3304																								274, 370										442, 1341															1363, 2223	2239, 2478
5,553	155,360	45988	Discharge summary	report	Admission Date: [2131-2-25] Discharge Date: [2131-3-6] Date of Birth: [2076-9-7] Sex: F Service: MEDICINE Allergies: Penicillin G Attending:[First Name3 (LF) 1148] Chief Complaint: Knee pain and mental status changes Major Surgical or Invasive Procedure: Lumbar puncture arthocentesis Steroid injection into R knee History of Present Illness: 54 yo female with hx of polysubstance abuse, HIV, and recurrent knee and chest pain presents with knee pain and confusion. Unable to obtain history as pt will not respond to verbal command. Pt is well known to the ED and often presents complaining of chest pain and knee pain requesting pain medications. Per ED team the patient presented complaining of her usual knee pain but was somewhat more agitated. She denied using any illicit substances but became severely agitated and was given IM haldol 5mg. She seen putting something in her pants and on exam the staff found a glass pipe. AP view of the pelvis was performed to rule out foreign body which was negative. LP was performed which revealed lymphocytic pleocytosis and she was started on vancomycin, ceftriaxone, and acyclovir. Labs revealed that she was in acute renal failure with elevated CK's with tox screen positive for opiates and cocaine. Her only complaint at this time is rt knee pain. She denies fever, chills, neck stiffness or photophobia. Past Medical History: 1. HIV secondary to intravenous drug use x16 years. CD4 count as discussed above. 2. Has a history of MSSA bacteremia in [2126-8-22]. 3. Pneumonia. 4. Bronchitis. 5. Asthma. 6. Hypertension. 7. Herniated disk. 8. Neuropathy secondary to HIV. 9. Remote history of polysubstance abuse. 10. ? ovarian cancer Social History: SOCIAL HISTORY: Patient is homeless and lives in a shelter. She has an autistic son. She smokes [2-24] cigarettes per day. Denies any use of alcohol or drugs - although previous records indicate opiate and cocaine use Family History: Family hx: Mother had MI (unknown age) Physical Exam: T 98.3 HR 110 BP 120/64 RR 14 O2Sat 98% [Female First Name (un) ] Gen-arousable to loud voice, otherwise NAD HEENT-PERRL, exophthalmos, neck supple, ant and supraclavic shoody LAD, thyroid not enlarged and no bruit Hrt-tachy RR, nS1S2 diffuse flow murmur across the precordium Lungs-CTA bilat Abd-soft, NT, ND, no HSM, NABS Extrem-2+ rad and dp pulses, left knee effusion which is warm but no erythema, painful ROM of left knee but able to flex to 120 degrees and fully extend Neuro-pt noncompliant with exam Skin-no clear injection sites Pertinent Results: [2131-2-25] 09:27PM JOINT FLUID WBC-900* RBC-[Numeric Identifier ]* POLYS-36* LYMPHS-16 MONOS-46 MACROPHAG-2 [2131-2-25] 09:27PM JOINT FLUID NUMBER-NONE [2131-2-25] 08:58PM GLUCOSE-98 UREA N-44* CREAT-1.6# SODIUM-136 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-21 ANION GAP-15 [2131-2-25] 08:58PM CK(CPK)-1337* [2131-2-25] 08:58PM CK-MB-29* MB INDX-2.2 cTropnT-0.03* [2131-2-25] 08:58PM CALCIUM-7.4* PHOSPHATE-3.2# MAGNESIUM-2.3 [2131-2-25] 08:58PM TSH-0.023* [2131-2-25] 01:35PM CK(CPK)-1464* [2131-2-25] 12:00PM CEREBROSPINAL FLUID (CSF) PROTEIN-39 GLUCOSE-64 [2131-2-25] 12:00PM CEREBROSPINAL FLUID (CSF) WBC-9 RBC-0 POLYS-0 LYMPHS-97 MONOS-3 [2131-2-25] 12:00PM CEREBROSPINAL FLUID (CSF) WBC-29 RBC-12* POLYS-0 LYMPHS-90 MONOS-10 [2131-2-25] 11:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-POS amphetmn-NEG mthdone-NEG [2131-2-25] 11:45AM URINE COLOR-Amber APPEAR-Hazy SP [Last Name (un) 155]-1.022 [2131-2-25] 11:45AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG [2131-2-25] 11:45AM URINE RBC-0-2 WBC-[3-26] BACTERIA-NONE YEAST-NONE EPI-<1 [2131-2-25] 11:45AM URINE GRANULAR-0-2 [2131-2-25] 10:09AM TYPE-[Last Name (un) ] COMMENTS-GREEN [2131-2-25] 10:09AM LACTATE-3.2* [2131-2-25] 10:00AM GLUCOSE-74 UREA N-55* CREAT-3.6# SODIUM-138 POTASSIUM-4.0 CHLORIDE-94 TOTAL CO2-21* ANION GAP-27* [2131-2-25] 10:00AM estGFR-Using this [2131-2-25] 10:00AM ALT(SGPT)-42* AST(SGOT)-93* CK(CPK)-2118* ALK PHOS-90 AMYLASE-227* TOT BILI-0.6 [2131-2-25] 10:00AM LIPASE-43 [2131-2-25] 10:00AM cTropnT-0.13* [2131-2-25] 10:00AM CALCIUM-8.3* PHOSPHATE-10.2# MAGNESIUM-2.0 [2131-2-25] 10:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2131-2-25] 10:00AM NEUTS-78.5 LYMPHS-14.7* MONOS-6.1 EOS-0.4 BASOS-0.2 [2131-2-25] 10:00AM PLT COUNT-343 [2131-2-25] 10:00AM PT-11.8 PTT-29.9 INR(PT)-1.0. . Pelvic XR IMPRESSION: Small radiodensities over the left pelvis annot be localized on this single projection, but are likely vascular calcifications . Knee XR IMPRESSION: No acute fracture or dislocation. Extensive degenerative change of the lateral compartment as above. Small right knee joint effusion . Admission CXR IMPRESSION: No acute pulmonary process. . CT Head IMPRESSION: 1. No acute hemorrhage or mass effect. 2. No significant change from [2129-1-1], including small subtle low attenuation focus of the left frontal periventricular white matter consistent with remote lacunar infarct. . R knee CT scan: IMPRESSION: 1. Extensive erosive changes and destruction of the lateral joint compartment of the knee with relative sparing of the medial compartment and patellofemoral compartment. These changes have steadily progressed dating back to previous radiographs from [2129-5-8]. The most likely etiology would be an low grade infectious process and given the HIV status of the patient, atypical infections (TB, fungal) should be considered. Other inflammatory arthropathies and synovial proliferative processes such as rheumatoid arthritis, PVNS and gout also should be considered. 2. No evidence of fracture. 3. Small loose bodies within the joint space. Large, joint effusion. . TTE: Conclusions: The left atrium is normal in size. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. Physiologic mitral regurgitation is seen (within normal limits). The left ventricular inflow pattern suggests impaired relaxation. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . JOINT FLUID ANALYSIS WBC RBC Polys Lymphs Monos Macro [2131-2-25] 09:27PM 900* [Numeric Identifier ]* 36* 16 46 2 Source: Knee JOINT FLUID Crystal [2131-2-25] 09:27PM NONE Source: Knee . [2131-2-25] 9:27 pm JOINT FLUID Source: Knee. ACU & DAS ADDED PER DR.[First Name (STitle) ] [Doctor Last Name 9406] ([Numeric Identifier ]) [2129-3-1]. GRAM STAIN (Final [2131-2-25]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2131-2-28]): NO GROWTH. ACID FAST SMEAR (Final [2131-3-2]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Pending): Brief Hospital Course: A/P 54 yo female with hx of polysubstance abuse, HIV, and recurrent knee and chest pain presents with knee pain and confusion. s/p tap of R knee. . Mental Status change-Most likely etiology is cocaine overdose. Believe elevated CK on admission was from cocaine as well. Head CT negative, no trauma. Lymphocytic pleocytosis on LP not concerning for bacterial meningitis and CSF did not grow bacteria. TSH was checked and was low but T3/4 were normal. Can recheck as outpatient. Mental status was back to normal by time transferred to floor [2131-2-28]. . Knee effusion- s/p arthrocentesis, no crystals on analysis of joint fluid. No evidence of septic joint. C/w hemarthrosis from mechanical fall. See by ortho and had CT scan of knee. Patient would benefit from TKR and should follow up with ortho as an outpatient. Given injection into R knee of ketalog and lidocaine on [3-6]. Maintained on MS Contin 15mg [Hospital1 ] with percocets prn. Was able to ambulate with walker and cleared by PT for discharge. . ARF-Likely related to poor PO intake and not likely elevated CK. Returned to baseline with IV hydration. . HIV-Prior CD4 count of 701. Patient said no HAART for over a year. Recommend follow up with [Hospital3 6616] for further evaluation. . HTN-Very elevated blood pressure. Evidence of mild diastolic dysfunction on TTE. Want to avoid beta blockers with active cocaine use. Given clonidine patch and lisinopril. . SVT-On evening of [2130-2-27] had run for apparent AVNRT. Broke with adenosine. TTE structurally normal. Not using beta blockers because of cocaine use. No further intervention. . Polysubstance abuse-Seen extensively by social work for both substance abuse and homelessness. No bed available at [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) ] house but placed on wait list. Given emotional support while here. Did not require valium on [Doctor Last Name ] scale. . Elevated troponin-no ischemic ECG changes. Troponin elevation due to cocaine and ARF. Troponins have trended down. . Uterine cancer: Question of history in past. Encouraged patient, esp with h/o HIV, to follow up for gyn appointment and pap smear. She did not want an appointment made for her. . Infection-Patient given 7 days levofloxacin while in house. Unclear source of infection and no fevers. Medications on Admission: (Not taking this meds consistently prior to admission) 1. Sertraline 2. Lamivudine 3. Indinavir 4. Nevirapine 5. Percocet 6. Moexipril Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:75 Tablet(s) Refills:0 2. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:45 Tablet Sustained Release(s) Refills:0 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Disp:1 1 Refills:2 4. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday). Disp:4 Patch Weekly(s) Refills:2 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Cocaine abuse Prerenal azotemia leading to acute renal failure HIV disease Hypertension Osteoarthritis and hemarthrosis Discharge Condition: Good Discharge Instructions: You were admitted with change in mental status believed to be from cocaine use. Please stop taking cocaine. It is dangerous to continue. . You have HIV and need to follow up in [Hospital3 6616] for further management of the disease. . You have significant hypertension that could become dangerous if it becomes more elevated. Please change the clonidine patch once a week (Tuesday) and take the lisinopril daily. You need to follow up with a primary care clinic in the next 2 weeks to get your blood pressure and lab work rechecked (to check that your kidneys are ok). . You have a follow up appointment for your right knee to be evaluated for further injections and possible repair. Followup Instructions: Please make a follow up appointment with your a primary care doctor in the next 2 weeks. Please make a follow up appointment with a gynecologist in the next month for a pap smear and follow up of ?uterine cancer. Provider: [Last Name (NamePattern4) ]. [First Name (STitle) ] [Doctor Last Name 9406] Phone:[Telephone/Fax (1) 457] Date/Time:[2131-4-10] 9:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10486], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2131-4-13] 3:20	[ "304.00", "728.88", "276.52", "042", "304.20", "844.9", "584.9", "493.90", "427.89", "715.36", "401.9", "E888.9", "355.8" ]	icd9cm	[ [ [] ] ]	[ "03.31", "81.91" ]	icd9pcs	[ [ [] ] ]	10721, 10727	7506, 9866	307, 368	10891, 10898	2615, 7452	11638, 12170	1997, 2037		10052, 10698		10748, 10870		9892, 10029			10922, 11615									2052, 2596																						7483, 7483		232, 269										396, 1409															1431, 1741	1773, 1981
45,017	172,232	37535	Discharge summary	report	Admission Date: [2117-12-28] Discharge Date: [2118-1-1] Date of Birth: [2056-5-26] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5893] Chief Complaint: Septic shock, cardiogenic shock Major Surgical or Invasive Procedure: TEE History of Present Illness: This is a 61-year-old gentleman with no known PMHx, who presented to [Hospital3 ] on [2117-12-27] via EMS after being found down, lethargic, and minimally responsive on floor of his home. The door to his house was reportedly open and his neighbors called the police when patient was apparently struggling to get up and muttering about shoveling his walkway. His sister-in-law has limited information about his presentation, though reports the neighbors had seen patient apparently of normal mental status and working in his yard earlier in day on [2117-12-27] prior this incident. . Upon presentation to [Hospital3 2737], patient was hypotensive with SBP in 90s and temperature of 96 at arrival. Was initially in [Last Name (un) ] with Cr of 1.4, though marginally improved to 1.1 prior to transfer. Mr. [Known lastname 59243] was noted to have a HCT elevation to 55.2 at [Hospital1 ] along with leukocytosis of 22 with 25% bands. His lactate was initially 5.2, though fell to 4.2 prior to transfer following 3L IVF. Trop-I was 0.113 at presentation, and remained stable throughout stay at [Hospital1 ]. Bedside ECHO performed and found to have EF 15%. Four out of four bottles from admission at [Hospital1 ] are reported as having gram positive cocci with preliminary speciation of staph aureus. Patient was given Vancomycin and imipenem/cilastatin and was started on norepinephrine for hypotension. Reported to have gangrenous left leg presumably due to frost bite. Additionally, had elevated INR to 5 and platelet count low at 69. Albumin of 2.2. AST 73 with nl ALT. Alk Phos 4.9, Tbili 4.3. Given his laboratory derangement, CT abdomen was obtained and reportedly abnormal in that there was increased density in the gallbladder consistent with noncalcified stones or sludge. Also noted to have small right pleural effusion and anasarca. Minimal information about his interactions and mental status at [Hospital1 ], though was evident that patient was conversant. He had a head CT reported to have no abnormalities. Was noted that patient does not normally receive his care at [Hospital1 ]. . [Name (NI) ] sister [Name (NI) 16883] reports that patient does not ever go to the doctor. His family tries to convince him to get regular check-ups, but he always refuses to go. Patient has overall been feeling unwell since [Holiday ]. He had decreased appetite and was noted to be tired and "lethargic." [Name (NI) ] sister notes that she went to visit him a couple of weeks ago and he was in bed looking like he was "dead" but woke up sluggishly after she yelled at him. She notes that the patient used to have heavy drinking, but had a friend who died from drinking and thus he has not had a drink in a couple of decades. . REVIEW OF SYSTEMS: unable to obtain due to intubated and sedated status Past Medical History: according to patient's sister Arthritis, but no additional known problems. [Name (NI) ] does not go to see doctors. Social History: according to patient's sister, [Name (NI) 16883] [Name2 (NI) ] lives alone in [Location (un) 13360], though two sisters live close by. Patient is reportedly independent and takes care of himself. His sister, [Name (NI) 16883] notes that patient has always kept to himself. [Doctor First Name 16883] will drive around to get groceries for him as patient has never had a license to drive. Patient used to work in a shoe factory, though is out on disability due to arthritis in his back and hands. Tobacco: Denies EtOH: Drank beer in past, though sister feels that patient has not drank in about 20 years. Illicits: Denies Family History: Reviewed and non-contributory Physical Exam: VS: T 99.6, HR 114, BP 94/74, RR 24, O2Sat 95% (AC Vt 500, f 14, PEEP 5, FiO2 100%) GEN: Intubated and sedated HEENT: Right pupil larger than left, though both round and reactive to light, cannot comply with EOM exam, oral cavity with dry mucosa and coiled OG tube in his mouth, poor dentition NECK: No [Doctor First Name ] PULM: CTAB anteriorly CARD: Tachycardic, nl S1, nl S2, no M/R/G ABD: Obese, anasarca, absent bowel sounds, soft, non-distended, non-tympanitic EXT: Left foot is cold and without dopplerable pulses, there are multiple ulcer on dorsum of foot that have necrotic eschar, though no active bleeding from these sites, BLE with 2+ pitting edema from feet to above the knees, foot care is deplorable with heaping growth of unkempt toenails bilaterally, 1+ pitting edema of BUE SKIN: Multiple non-palpable, non-blanching, purpuric 0.5 to 1 cm round lesions scattered across abdomen. Additionally, BLE with petechiae, non-blanching, with NEURO: Sedated Pertinent Results: [2117-12-28] 10:16PM TYPE-ART PO2-462* PCO2-30* PH-7.36 TOTAL CO2-18* BASE XS--6 [2117-12-28] 08:05PM GLUCOSE-224* UREA N-67* CREAT-1.4* SODIUM-142 POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-21* ANION GAP-19 [2117-12-28] 08:05PM ALT(SGPT)-30 AST(SGOT)-89* LD(LDH)-393* CK(CPK)-489* ALK PHOS-278* AMYLASE-34 TOT BILI-7.9* [2117-12-28] 08:05PM CK-MB-12* MB INDX-2.5 cTropnT-0.08* [2117-12-28] 08:05PM ALBUMIN-2.6* CALCIUM-8.0* PHOSPHATE-4.9* MAGNESIUM-2.6 [2117-12-28] 08:05PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc Ab-NEGATIVE [2117-12-28] 08:05PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2117-12-28] 08:05PM HCV Ab-NEGATIVE [2117-12-28] 08:05PM WBC-14.8* RBC-5.71 HGB-16.2 HCT-52.4* MCV-92 MCH-28.4 MCHC-30.9* RDW-14.7 [2117-12-28] 08:05PM NEUTS-91.6* BANDS-0 LYMPHS-5.9* MONOS-2.3 EOS-0.1 BASOS-0.2 [2117-12-28] 08:05PM PT-19.8* PTT-30.8 INR(PT)-1.8* ECHO [12-29]:The left atrium is dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis (LVEF = 15-20%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. The right ventricular cavity is dilated with depressed free wall contractility. The aortic valve leaflets are mildly thickened. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderately dilated and severely hypokinetic left ventricle. Dilated and hypokinetic right ventricle. Diastolic dysfunction with elevated filling pressures. Mild mitral regurgitation. At least mild pulmonary artery systolic hypertension. No vegetation or abscess seen. ABDOMINAL ULTRASOUND [12-29]: 1. Abdominal ascites and right pleural effusion. 1. Slightly thickened gallbladder wall with biliary sludge. Given patient's ICU stay and known hypoalbuminemia, this is a nonspecific finding, especially in the absence of other features for cholecystitis. CTA [12-29]: IMPRESSION: 1. Moderate ascites within abdomen and pelvis. 2. Patent lower limb arteries above the level of the ankle. The right posterior tibial artery is occluded beyond the level of the ankle. The left dorsalis pedis artery is occluded. TEE [12-30]: Trace aortic regurgitation with mild aortic leaflet thickening, but no 2D echocardiographic evidence for endocarditis. Biventricular systolic dysfunction. Brief Hospital Course: This is a 61-year-old man with no known PMHx, presented to [Hospital3 2737] on [2117-12-27] via EMS after being found down, lethargic, and minimally responsive on the floor of his home. . #. Hypotension: Likely multifactorial from distributive shock and cardiogenic shock. Blood cultures from [Hospital3 ] showed 4/4 bottles positive for staph aureus. Patient was initially treated with Vancomycin, and then switched to Nafcillin when organism discovered to be MSSA. He was also broadly covered with cefepime (eventually switched to cipro) and flagyl. Source for infection was never definitively identified, though most likely portal of entry was through grossly necrotic foot ulcers. A TEE was done, which was did not show any vegetations to suggest endocarditis (given staph bacteremia). [Hospital ] hospital course, patient continued to spike fevers and require vasopressors despite adequate fluid rescuscitation. Cardiogenic shock is also likely in the setting of an EF of 15-20%. According to patient's sisters, he had not seen a doctor in many years, and his baseline cardiac status is unknown. He was ruled out for a myocardial infarction. Unknown etiology of cardiac failure however, patient undoubtedly had coronary artery disease with a hemaglobin A1C of 11. . #. Respiratory Status: Patient was initially intubated at [Hospital3 ] to ensure a safe transfer to [Hospital1 18]. He was never in acute respiratory failure. The team considered extubation however, it was felt that patient's overall picture was too tenuous, and his mental status was unknown. He continued to be intubated throughout his hospital stay. . #. Jaundice: Patient LFTs and bilirubin continued to rise throughout admission. A right upper quadrant ultrasound was performed, which showed sludge but no evidence of cholecystitis. Hepatology seriologies were negative. LFTs continued to rise in the setting of sepsis and resultant liver failure. . #. Coagulopathy: Patient presented to [Hospital3 ] with an INR of 5 and platelets of 69. Throughout his stay in the [Name (NI) 153], PT/PTT and INR continued to be elevated and platelets decreased. Unclear etiology of coagulopathy but again, most likely sepsis leading to synthetic failure and poor platelet function. . #. Dry gangrene: Patient with unknown chronicity of his bilateral foot ulcers, though presents with necrotic lesions on left and right feet. Vascular surgery was consulted who recommended bilateral amputations. However, patient's family stated that he would not have wanted to live without his feet. As such, amputation was deferred. A CTA of legs was performed, which showed patent vessels up until his ankles. . #. [Last Name (un) ]: Patient with unknown baseline Cr, though presented with creatinine of 1.4 in setting of BUN of 67. Taking into account entire clinical picture, it is reasonable to assume that acute kidney injury is a combination of pre-renal azotemia and ATN from poor perfusion. Creatinine and BUN continued to rise throughout hospital course. . GOALS OF CARE: Extensive discussions were held with patient's family, and gravity of situation was discussed. Family understood that maximal medical efforts had been attempted, but patient's condition continued to deteriorate. The decision was made to make patient DNR, and goals of care became patient comfort. Pressors were discontinued, and patient eventually passed at 1710 on [2118-1-1]. Medications on Admission: TRANSFER MEDICATIONS: 1) Primaxin 500mg IV Q8H (last dose charted at 1600 [12-28]) 2) Vancomycin 1G IV Q12H (last dose charted at 0900 [12-28]) 3) Norepinephrine drip 10 mcg/hr 4) Insulin sliding scale 5) NS 250 mL/hr for 3 L then 150 mL/hr continuous Discharge Medications: Patient expired. Discharge Disposition: Expired Discharge Diagnosis: Patient expired. Discharge Condition: Patient expired. Discharge Instructions: Patient expired. Followup Instructions: Patient expired.	[ "785.51", "440.24", "286.7", "427.32", "570", "995.92", "789.59", "584.5", "707.14", "511.9", "785.52", "276.2", "038.11" ]	icd9cm	[ [ [] ] ]	[ "86.11", "38.91", "38.93", "96.72", "88.72" ]	icd9pcs	[ [ [] ] ]	11736, 11745	7905, 11384	347, 352	11805, 11823	5103, 7882	11888, 11907	4066, 4097		11695, 11713		11766, 11784		11410, 11410			11847, 11865									4112, 5084																			3186, 3242					276, 309									11432, 11672	380, 3167															3264, 3388	3404, 4050
21,456	161,520	49611	Discharge summary	report	Admission Date: [2179-6-15] Discharge Date: [2179-6-21] Date of Birth: [2100-8-13] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 443] Chief Complaint: presyncope Major Surgical or Invasive Procedure: pericardiocentesis History of Present Illness: 78 year old woman with COPD, prior CVA, DM, HTN, recent symptoms of presycnope, nausea, increasing SOB. Admitted one day PTA to [Location (un) 620] after having fallen out of bed and having one episode of N/V. She was ruled out for any cardiac event and has been getting treated with nebs and levofloxacin for possible COPD exacerbation given that she had productive sputum at that time. In [2179-5-2], she had a CT scan to evaluate for persistent atelectasis and to look for pulmonary nodules. Found to have bilateral pleural effusions and large pericardial effusion. Repeat CTA on [2179-6-14] as part of her workup showed increased size of both effusions. A TTE at [Location (un) 620] demonstrated a moderate-large pericardial effusion with early signs of tamponade, pulmonary hypertension and a normal LVEF. She was transferred for further work up. . After arrival to the [Hospital1 ], patient was evaluated on the floor. VS were stable except for a pulsus of 12. Exam revealed JVP to the angle of the jaw. Cardiac enzymes were negative. Initial workup for pericardial and pleural effusion was performed (TSH, ESR, anti-dsDNA, complement were sent). Given RA collapse on TTE from [Location (un) 620] and positive pulsus, patient was sent for pericardiocentesis. She went to cath lab overnight. Cath report from [6-16] indicated that a pulsatile arterial-appearing blood was expressed at first needle pass. Needle was withdrawn and local pressure applied. 350cc greenish fluid was aspirated. Patient was HD stable throughout procedure, then transferred to the CCU for monitoring. . At arrival in the CCU, the patient only c/o mild-moderate chest soreness over the puncture site without any radiation. She denies any SOB, palpitations, fevers, nightsweats but noted some weight loss over the last few months (unclear amount). . ROS at that time was negative for abdominal pain, bloody stools, urinary symptoms, but positive for a dry cough. . REVIEW OF SYSTEMS (at time of admission): Denies any prior history of deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. Denies recent fevers, chills or rigors. Denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: * HTN * prior UTI's * hx of recent falls * Diabetes mellitus * COPD/asthma * CVA in [2178] * Microcalcifications of both breasts and cluster of dense, punctate calcifications of left breast (mammogram [2178-9-21]) * Hypercholesterolemia Social History: She now lives at [Location ] in [Location (un) 620]. . significant for 40 pack year smoking history, quit in [2161]. There is no history of alcohol abuse. Family History: Noncontributory. . Physical Exam: On admission: VS: T 97.8 BP132/78 HR95 RR18 O2 89% RA, 96% 3L Pulsus 12 Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVD to angle of the jaw. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. SYstolic murmur heard best at the base. . No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Decrease breath sounds bilaterally at the bases. Dullness to percussion. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ On transfer to CCU: VS: T 97.4 BP118/58 HR89 RR16 O2 100% 3L NC Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect appropriate. HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVD of approx 8. Breast: No overt, large masses palpation. Only strings in left upper quadrant of left breast and one small, mobile nodule in right lower quadrant of right breast palpable. No nipple discharge. CV: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Decrease breath sounds bilaterally at the bases with dullness to percussion. No TTP over chest. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. LNs: No cervical, axillary or inguinal LAD . Pulses: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: EKG demonstrated sinus. 89 bpm. nl axis nl intervals. Deep TWI in V1-V5 which are new compared to [2178]. No ST changes. . 2D-ECHOCARDIOGRAM performed on [2179-6-15] demonstrated: No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace 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 left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a moderate to large sized pericardial effusion. No right ventricular diastolic collapse is seen. There is intermittent, sustained right atrial invagination (varies with repsiration), consistent with early tamponade. . . CTA chest [2179-6-14]- Central pulmonary arteries remain patent. No filling defect is identified. There is a large pericardial effusion. Considerable atherosclerotic calcification is present including coronary artery calcification. Mediastinal structures are otherwise unremarkable. There are moderate pleural effusions bilaterally. There is underlying compressive atelectasis as well as plate-like atelectasis in the middle lobe and lingula. Degenerative arthritic changes are present in the spine. No osteolytic or osteoblastic lesion is identified.Compared with the previous study of [2179-5-10], pleural effusions and the pericardial effusion have increased in size. . CT chest [2179-5-10] - There is evidence of bilateral pleural effusions and a large pericardial effusion. There is a small amount of subsegmental atelectasis in the lingula and within the right middle lobe. Some of these are likely relaxation changes because of the large pleural pericardial fat pads adjacent. Mild dilatation of the ascending aorta is seen. Similarly, mild dilatation of the pulmonary arteries to about 3 cm is seen. The examination was not tailored to evaluate the pulmonary arteries but the visualized arteries appear normal. No masses or nodules are seen. . Cath [2179-6-16]: 1. Pericardiocentesis was performed through subxiphoid entry. 2. Pulsatile arterial-appearing blood was expressed at first needle pass. Needle was withdrawn and local pressure applied. 3. Upon second pass, initial pericardial pressure of 9 mmHg was recorded. A total of 350 cc of greenish fluid was removed and sent to the pathology laboratory for diagnostic studies. 4. Drain was placed and sawn in place. 5. Post tap bedside echocardiogram showed no residual pericardial fluid. 6. patient remained hemodynamically stable throughout the procedure and early post procedure course. . Post-pericardiocentesis TTE [2179-6-16]: Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular systolic function is normal. There is a very small residual pericardial effusion at the apex. There is no echocardiographic evidence of tamponade. . LABORATORY DATA (from [Location (un) 620]): CK 24-->26-->14 Troponin 0.01-->0.01--0.01 CK-MB wbc 9.1, hgb 12, hct 36.4, plt 403, K 3.8, INR 1.0 Cr 1.2 . LABS AT [Hospital1 ]: [2179-6-15] 07:25PM WBC-7.4 RBC-3.43* HGB-10.2* HCT-31.5* MCV-92# MCH-29.7# MCHC-32.3 RDW-15.5 [2179-6-15] 07:25PM CK-MB-NotDone cTropnT-<0.01 [2179-6-15] 07:25PM CK(CPK)-23* [2179-6-15] 07:25PM GLUCOSE-93 UREA N-18 CREAT-1.2* SODIUM-137 POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-28 ANION GAP-11 . Pericardial fluid [6-16]: T. prot: 3.3 Glu: 100 LDH: 133 Amylase: 11 WBC: 100 RBC: 9150 Diff: 4 polys, 35 lymphs, 30 macro, 30 mono . Pleural fluid: T. prot: 2.6 Glu: 129 LDH: 130 WBC: 365 RBC: 55 Diff: 14 polys, 25 lymphs, 51 monos, 10 mesos . Labs on discharge: Cr 1.0 WBC 9.0 Hct 31.2 Plt 441 Brief Hospital Course: Pt is a 78 year old female from nursing home with HTN, HL, DM, COPD, s/p [Hospital ] transferred from [Location (un) 620] for evaluation of pericardial effusion. Found to have early tamponade on echo and on clinical exam. Now s/p pericardiocentesis with 350cc fluid drained, transferred to CCU for monitoring. . 1)Pericardial effusion - Appears to be chronic given was present on prior imaging. DDx includes idiopathic, TB or viral pericarditis, post MI, HIV, aortic dissection, malignancy (including hodgkin's, lung, breast), rheumatic, hypothyroid. No signs of dissection on CTA. Colonoscopy in [2178] negative. No LAD on CT making lymphoma unlikely. Did have mammogram in [9-/2178], per PCP needs repeat to review calcifications seen. TSH 1.9 in 12/[2178]. No history of TB exposure (no PPD necessary at this point given low risk). No clear prodrome of pericarditis, viral or otherwise. Patient went to cath lab on [6-16] for pericardiocentesis and drain placement. Pain controlled with NSAIDs and oxycodone PRN. Drain was pulled [6-17] after output decreased (400cc total) with post-procedure TTE showing only minimal effusion at the apex. No elevated JVP or clinical signs of tamponade upon transfer to CCU. Pericardial fluid was sent for culture and cytology. On [6-18] [2-2] culture bottles became positive for coag negative staph, however it was felt that this was most likely a contaminant given gram stain not consistant with acute infection (no organisms or PMLs) and patient was afebrile with normal WBC. Given the extremely low suspicion for purulent pericarditis antibiotics were witheld. Workup for other causes of effusion included normal ESR, normal TSH, negative ANCA and anti-dsDNA Ab. Fluid was negative for malignant cells. Additionally, she has also had pan-scans that have not shown any obvious malignancy, however, pt needs repeat mammogram as outpatient for malignancy w/u given suspicious mammogram in the past. . 2) Pleural effusions - Likely same process as pericardial effusion. Had diagnostic right thoracentesis on [6-17] with removal of 450cc of straw colored fluid. Exudative by LDH. No clear etiolgy. Pleural fluid culture was negative, however cytology was pending at time of dicharge. Patient's respiratory status improved and she was weaned off oxygen with an O2 sat of 94% on RA. . 3) CAD - No previous history of CAD. On ASA for primary prevention. Decreased to 81mg daily. Ruled out by enzymes at OSH. EKG with deep T waves in precordial leads possibly suggesting resolving pericarditis. Not thought to have any active ischemia. . 4) CVA - last year. On ASA and aggrenox. Continued on ASA which was decreased to 81mg as above. Held aggrenox in setting of procedures. Restarted on [6-18]. . 5) Hyperlipidemia - Continued simvastatin. . 6) HTN - Normotensive upon transfer to CCU. Restarted home meds (Lisinopril 2.5mg qd and Metoprolol 25mg tid). . 7) Chronic renal failure - likely due to hypertension and diabetes. Cr of 1.2 on transfer, Appears to be at baseline (0.9-1.2). - Renally dose meds. - Unlikely to have caused uremic pericarditis. . 8) Bronchitis - on levofloxacin upon transfer. Afebrile since transfer to [Hospital1 ]. Discontinued abx since no signs of COPD flare and no clear indication of bronchitis. . 9) COPD - stable. Continue montelukast and nebs. . 10) Chronic anemia - Hct baseline around 28-35. Currently stable. Continued FeSO4. . 11) DM - At home patient is on metformin. Held oral hypoglycemics initially and covered with SSI. Metformin restarted on [6-18]. . 12) Psych - baseline dementia but A&O x3 on transfer and responding adequately to all questions. Geriatrics was consulted per PCP. [Name10 (NameIs) ] was continued on citalopram. Psych was consulted while pt. was in-house given persistantly flat affect and concern for worsening depression. Psychiatry did not feel that there was an acute change in her depression and did recommend any medication changes. Psychiatry felt that she would benefit more from continued monitoring by a psychiatrist as an outpatient once at rehab to further clarify her symptoms and need for medication adjustment. . 13) FEN - Cardiac, [Doctor First Name ] diet. . 14) PPX - sc heparin, bowel regimen, Vitamin D, Calcium, repleted lytes as needed. . 15) Access - PIV . 16) Code - DNR/DNI, discussed with PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] and HCP [Name (NI) ] [Name (NI) 3314] . 17) Communication - son [Name (NI) ] [Name (NI) 3314] (HCP) Medications on Admission: CURRENT MEDICATIONS: calcium carbonate 500mg [Hospital1 ], last given at 9am today Ferrous sulfate last given at 9am today Linsinpril 2.5mg given today at 9am Metformin 1000mg [Hospital1 ] given 9am Lopressor 25mg tid last given at 9am Vitamin D 400 taken at home yesterday Insulin regular sliding scale (none today) Aggrenox last given at 2pm today Aspirin 325mg daily at 9am today Levaquin 500mg po given last night at 9pm lovenox 40mg sq every 24 hours, last given at 9pm yesterday MVI Singulair 10mg given at 9pm last night Zocor 20mg given last night Celexa 10mg given at 9am Duoneb every four hours, given at 9am and 2pm Zofran 4mg IV last given at at 12am on [2179-6-15] mag sulfate 2gram given this morning at 6am . MEDICATION UPON TRANSFER TO CCU: * Ipratropium Bromide Neb 1 NEB IH Q6H:PRN * Acetaminophen 325-650 mg PO Q4-6H:PRN pain * Levofloxacin 250 mg PO Q24H * Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN * Montelukast Sodium 10 mg PO DAILY * Aspirin 325 mg PO DAILY * Multivitamins 1 CAP PO DAILY * Calcium Carbonate 500 mg PO BID * Neutra-Phos 2 PKT PO BID * Citalopram Hydrobromide 10 mg PO DAILY * Senna 1 TAB PO BID:PRN * Docusate Sodium 100 mg PO BID * Simvastatin 20 mg PO DAILY * Ferrous Sulfate 325 mg PO DAILY * Heparin 5000 UNIT SC TID * Vitamin D 400 UNIT PO DAILY * Insulin SS Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 12. Insulin Lispro (Human) 100 unit/mL Solution Sig: ASDIR Subcutaneous ASDIR (AS DIRECTED). 13. Potassium & Sodium Phosphates [Telephone/Fax (3) 4228] mg Packet Sig: One (1) Packet PO BID (2 times a day). 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr Sig: One (1) Cap PO BID (2 times a day). 17. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 18. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 19. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q4H (every 4 hours). 20. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] Discharge Diagnosis: Primary Diagnosis: 1. Pericardial tamponade, s/p pericardiocentesis 2. Pericardial and pleural effusions of unclear etiology 3. COPD 4. Diabetes mellitus 5. Hypertension . Secondary Diagnosis: 1. h/o Stroke Discharge Condition: Afebrile. Hemodynamically stable. Tolerating PO. Discharge Instructions: You have been found to have increased fluids along the linings of your heart and lungs. Your fluid around your heart has been drained. You have received pain and anti-inflammatory medications for pain control. . Please call your primary doctor or return to the ED with fever, chills, chest pain, shortness of breath, nausea/vomiting, spontaneous bleeding or any other concerning symptoms. . Please take all your medications as directed. . Please keep you follow up appointments as below. Followup Instructions: Please follow up with: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2847], MD Phone:[Telephone/Fax (1) 719] Date/Time:[2179-6-23] 9:30 Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 252], M.D. Phone:[Telephone/Fax (1) 253] Date/Time:[2179-7-29] 1:45	[ "V12.59", "272.0", "585.9", "493.20", "403.90", "250.40", "281.9", "294.8", "423.9", "511.9" ]	icd9cm	[ [ [] ] ]	[ "34.91", "37.0" ]	icd9pcs	[ [ [] ] ]	17182, 17267	9517, 14084	325, 345	17520, 17571	5272, 9442	18108, 18428	3340, 3361		15452, 17159		17288, 17288		14110, 14110			17595, 18085									3376, 3376																								275, 287			9461, 9494					14131, 15429		373, 2872				17483, 17499				17307, 17461	3390, 5253						2894, 3140	3156, 3324
24,730	143,418	51154	Discharge summary	report	Admission Date: [2144-7-9] Discharge Date: [2144-7-14] Date of Birth: [2097-1-9] Sex: F Service: Medicine, [Doctor Last Name ] Firm HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old woman who, in [2136], had an 81.14-mm thick melanoma found on her right posterior thigh. In [2142-3-8], the patient had a right inguinal area lymph node resected with positive margins. Between [2142-4-7] and [2142-6-7], the patient from [2142-4-7] to [2143-4-8]. In [2142-8-8], a CT of the chest showed a right upper lobe nodule. In [2143-8-9], two more right upper lobe nodules were found. In [2143-12-9] a CT of the chest revealed left lower lobe nodule, and in [2144-3-8] a CT revealed pancreatic lesions times two, as well as new lesions in the left lower lobe and right upper lobe. Also noted was a subcutaneous mass in the patient underwent COG and a [Numeric Identifier 65163] trial beginning on [2144-5-11]. On [2144-6-22], the patient reported cough and fever and was started on Zithromax but continued to have a dry cough and dyspnea on exertion. One day prior to admission, the patient had fever to 100. Her oxygen saturation was apparently checked at home and found to be 91% on room air. The patient was sent to the Emergency Department for further evaluation. PAST MEDICAL HISTORY: Melanoma metastatic to lungs, pleura, pancreas, axilla. In [2136], status post resection of melanoma from right posterior thigh. In [2142-3-8], status post right inguinal lymph node resection with positive margins. Radiation therapy from [2142-4-7] through [2142-6-7]. In [2142-4-7] through [2143-4-8], the patient received interferon. In [2142-8-8], right upper lobe lung nodules were found. In [2143-12-9] new nodules were found in the left lower lobe. In [2144-3-8] pancreatic lesions were found. In [2144-4-7] subcutaneous axillary nodules were found. The patient experienced femoral neuropathy secondary to radiation therapy. MEDICATIONS ON ADMISSION: MSIR 24 st q.d., MS Contin p.o. b.i.d. (the patient did not know dose). In the Emergency Department the patient received Levaquin 500 mg intravenously times one, as well as Flagyl 500 mg intravenously times one, and morphine 2 mg intravenously times two, and 4 mg intravenously times two. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is married and smoked one to two packs of cigarettes per day times 30 years; she quit in [2143-12-9]. FAMILY HISTORY: The patient's father died at the age of 67 of leukemia. LABORATORY DATA ON ADMISSION: Complete blood count was notable for a white blood cell count of 14.8, hematocrit of 34, and platelets 636. The patient's Chem-7 revealed a sodium of 133, potassium of 4, chloride of 96, bicarbonate of 18, BUN of 15, creatinine of 0.5, glucose of 112. Anion gap of 19. Creatine kinase was 34, and troponin was 0.3. INR was 1.3, PTT was 27.8, PT was 13.9. PHYSICAL EXAMINATION ON ADMISSION: In general, the patient was a cachectic ill-appearing female with moderate respiratory distress. Vital signs were as follows: Temperature 97.6, heart rate 113, blood pressure 98/66, breathing 20 times per minute. HEENT revealed pupils were equal, round, and reactive to light. Oropharynx with dry mucous membranes. Neck revealed no jugular venous distention. Chest examination revealed pulmonary crackles at the right anterior upper field as well as decreased breath sounds and tubular sounds in the left side. Cardiovascular examination revealed tachycardia with no murmurs heard. Heart sounds were clear. Abdomen was soft, nontender, and nondistended, positive bowel sounds, positive subcutaneous nodule in the right upper quadrant. Extremities were without edema. RADIOLOGY/IMAGING: Other studies on admission included chest CT from [7-8] revealed extensive lymphadenopathy in the right axilla, especially in the superior region. There was a right hilar, and pretracheal, and precarinal lymphadenopathy; left-sided pleural effusion approximately halfway up the field; slight right shift of the mediastinum; right upper lobe pneumonia; right pleural based nodules; left lower lobe complete collapse. Chest x-ray on [7-8] revealed a new left-sided effusion as noted above, right high-powered border with questionable border. Electrocardiogram of [2144-7-8], revealed sinus tachycardia with a heart rate of 133, right bundle-branch block pattern with loss of R waves anteriorly, low voltages. Compared with [2144-4-7], the right bundle-branch block was new, and the voltages were significantly lower. HOSPITAL COURSE: The patient was admitted to the O-MED Service on [2144-7-8], due to her dyspnea and elevated temperatures at home. As noted above, CT and chest x-ray revealed multiple pulmonary nodules, as well as a large left-sided pleural effusion, and right upper lobe pneumonia. The patient was started on levofloxacin and Flagyl, and underwent 2-liter thoracentesis. Electrocardiogram showed low voltage. Echocardiogram revealed pericardial effusion with sustained right atrium and diastolic right ventricular collapse. Thus, the patient underwent a 350-cc pericardiocentesis and was transferred to the Coronary Care Unit with a pigtail drain. The drain was discontinued on [2144-7-11], without any complications. The patient's condition continued to wane despite her antibiotics and pleurocentesis and pericardiocentesis. The patient's husband did not want the patient to have home hospice secondary to concerns about the patient and her husband's children being at home. The husband, thus, preferred inpatient hospice. The patient and the patient's family changed the patient's status to DNR/DNI on [2144-7-10], and she was made comfort measures only. All medications and monitoring were discontinued except for morphine and Ativan. The patient was transferred to the medical floor on [2144-7-13]. On the morning of [2144-7-14], the cross-covering house officer was called to evaluate the patient for lack of spontaneous respirations. The house officer found the patient to be without spontaneous respirations, and without spontaneous heart beats, as well as to have fixed and dilated pupils bilaterally. The patient was thus pronounced dead on the morning of [2144-7-14]. DISCHARGE DIAGNOSES: 1. Widely metastatic melanoma. 2. Status post radiation therapy. 3. Status post chemotherapy. 4. Pneumonia. CONDITION AT DISCHARGE: The patient, as noted above, was pronounced dead on the morning of [2144-7-14]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 1736] Dictated By:[Last Name (NamePattern1) 1550] MEDQUIST36 D: [2144-7-15] 09:40 T: [2144-7-19] 07:02 JOB#: [Job Number ]	[ "197.2", "486", "V10.82", "197.8", "197.0", "518.0", "799.4", "423.9", "196.1" ]	icd9cm	[ [ [] ] ]	[ "37.0", "34.91" ]	icd9pcs	[ [ [] ] ]							2571, 2644	6428, 6562					2089, 2418	4704, 6407																										6577, 6930																			193, 1358									3054, 4686						1382, 2062	2435, 2554
54,939	113,645	36246	Discharge summary	report	Admission Date: [2199-5-3] Discharge Date: [2199-5-5] Date of Birth: [2166-10-3] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Female First Name (un) 82171] Chief Complaint: Tylenol PM overdose Major Surgical or Invasive Procedure: None History of Present Illness: 38 year old male with unknown past medical history (presumed depression as of [1-/2199]) found unresponsive with three wine bottles, suicide note and empty bottle of Tylenol PM (40 tablets) found next to him this evening. Receipt for the Tylenol PM was for 9:21 pm, [5-2]. A third party called EMS who brought him to [Hospital1 18] ED. No other drugs found at the scene. No signs of trauma. Per report, patient was found wearing multiple T-shirts from his bachelors party, with wife's wedding garter belt around his neck. Had recently told a friend he wished to be cremated. . In the [Hospital1 18] ED, initial VS: T98.1, HR123, BP133/81, RR30, O2 sat 100% on RA. The patient was initially minimally verbally responsive but protecting his airway, ABG 7.42/34/81. EKG showed sinus tachycardia with QTc 438 and QRS 92. Urinalysis negative for UTI and UTox negative for other substances. Labs were generally unremarkable except for Creatinine 1.3, INR 1.2 and serum alcohol level 56. LFTs currently normal. Serum tylenol still pending upon arrival to MICU. The patient became very agitated with Foley catheter placement, requiring Lorazepam 2mg IV. Haldol was avoided to prevent QTc prolongation. The patient also received Zofran 4mg for nausea and 3L IVF. Toxicology was consulted and recommended empiric NAC, which was started (first dose). They recommended against using activated charcoal since the patient likely ingested hours earlier and would be at risk for aspiration with his mental status. It was estimated that the patient consumed ~20 grams of tylenol and 1 gram of benadryl within the last 4.5 hours. . ROS: Patient arousable but garbled speech, does not endorse any complaints. Past Medical History: - L thumb tip avulsion (kitchen knife, [3-/2198]) - Depression Social History: Denies tobacco, illicit drug use. Reports 1-2 drinks per week. Of note, lived at home with wife until she recently moved out after being threatened repeatedly by patient. Family History: Schizophrenia Physical Exam: ADMISSION VS: Temp: 97.1 BP: 140/88 HR: 99 RR: 16 O2sat 99% on RA GEN: Sleeping soundly but responsive to verbal stimuli, follows commands, comfortable, NAD, garbled speech but appropriate HEENT: PERRL - dilated, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd RESP: CTA b/l with good air movement throughout, no wheezing/rhonchi/rales anteriorly CV: RR, S1 and S2 wnl, no murmurs/gallops/rubs ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAO. CN 2-12 intact. Moving all extremities. DISCHARGE VS: 97.9 80 125/80 15 99%RA GEN: Well appearing, NAD 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 wheezing/rhonchi/rales anteriorly CV: RR, S1 and S2 wnl, no murmurs/gallops/rubs ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAO. CN 2-12 intact. Moving all extremities. Pertinent Results: Blood Counts [2199-5-3] 01:10AM BLOOD WBC-7.0 RBC-4.49* Hgb-14.5 Hct-40.8 MCV-91 MCH-32.2* MCHC-35.4* RDW-12.9 Plt Ct-240 Coags [2199-5-3] 01:10AM BLOOD PT-13.8* PTT-23.1 INR(PT)-1.2* [2199-5-3] 10:06AM BLOOD PT-15.6* PTT-26.4 INR(PT)-1.4* [2199-5-5] 07:25AM BLOOD PT-12.6 PTT-23.5 INR(PT)-1.1 Chemistry [2199-5-3] 01:10AM BLOOD Glucose-97 UreaN-13 Creat-1.3* Na-143 K-3.8 Cl-104 HCO3-23 AnGap-20 [2199-5-5] 07:25AM BLOOD Glucose-98 UreaN-14 Creat-1.1 Na-139 K-4.0 Cl-99 HCO3-31 AnGap-13 LFTs [2199-5-3] 01:10AM BLOOD ALT-23 AST-22 AlkPhos-56 TotBili-0.6 [2199-5-3] 05:35PM BLOOD ALT-18 AST-15 LD(LDH)-157 AlkPhos-51 TotBili-1.0 [2199-5-5] 07:25AM BLOOD ALT-16 AST-13 LD(LDH)-158 AlkPhos-58 TotBili-0.7 Tox [2199-5-3] 01:10AM BLOOD ASA-NEG Ethanol-56* Acetmnp-210* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2199-5-3] 10:06AM BLOOD Acetmnp-52* [2199-5-3] 05:35PM BLOOD Acetmnp-6* [2199-5-4] 12:40AM BLOOD Acetmnp-NEG EKG [2199-5-3] Sinus tachycardia. There are non-diagnostic Q waves in the inferior leads. Non-specific ST-T wave changes. Brief Hospital Course: HOSPITAL COURSE This is a 38yo M who presented with a tylenol and benadryl overdose w/o significant signs of toxicity, stable over 48hrs, medically cleared, now being discharged to [Hospital1 ] 4 Psychiatric Service. . ACTIVE # s/p suicide attempt: Pt found unresponsive with a suicide note, admitted to medical ICU for management of tylenol/benadryl overdose as below, now stable and medically cleared. He was monitored by 1:1 sitter, with social work and psychiatry following patient regarding ongoing mental health and social issues, including reports from wife of patient being increasingly paranoid and "emotionally abusive". Patient expressed regret re: suicide attempt. After evaluation by Psychiatry service, patient is now being discharged to [Hospital1 ] 4 Psychiatric Service. . # Tylenol overdose: Patient admitted with tylenol overdose, estimated at 20g by toxicology service. Admission acetaminophen level of 210 at (~4hrs post ingestion). Patient received NAC and was monitored without major abnormality of LFTs, INR. Patient without any signs of significant toxicity at 48hrs post ingestion. . # Benadryl overdose: Patient admitted w delirium and agitation thought to be [1-2] to bendryl overdose, but was without significant QTc prolongation, hyperthermia, urinary retention. His mental status cleared and was without any prolonged toxicity at 48hrs post ingestion. . TRANSITIONAL 1. Code status - Patient remained full code 2. Pending - No labs/studies were pending at discharge 3. Transition of Care - Patient was medically cleared; after evaluation by psychiatry service, patient was accepted to [Hospital1 ] 4 Psychiatric Service. Medications on Admission: -Vitamin D2 Discharge Medications: None Discharge Disposition: Extended Care Facility: [Hospital1 69] - [Location (un) 86] Discharge Diagnosis: PRIMARY Tylenol Overdose Benadryl Overdose Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Last Name (Titles) 82172], It was a pleasure taking care of you at [Hospital1 827]. You were admitted for treatment of a tylenol and benadryl overdose. You were monitored and did not demonstrate any signs of lasting toxicity. You were medically cleared and are now being discharged to the [Hospital1 18] Psychiatric Service Followup Instructions: Please follow-up with the pschiatrists on the [Hospital1 18] Psychiatric Service [Month (only) 6436] ([Month (only) ]) [Name8 (MD) ] MD [MD Number(2) 82173]	[ "E950.4", "963.0", "293.0", "309.0", "584.9", "E950.0", "965.4" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	6383, 6453	4618, 6292	329, 335	6540, 6540	3499, 4595	7060, 7269	2368, 2383		6354, 6360		6474, 6519		6318, 6331			6691, 7037									2398, 3480																								270, 291										363, 2071											6555, 6667				2093, 2162	2178, 2352
1,076	141,828	46402	Discharge summary	report	Admission Date: [2173-11-12] Discharge Date: [2173-11-19] Service: SURGERY Allergies: Procardia Attending:[First Name3 (LF) 1481] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ERCP with plastic stent placement History of Present Illness: [Age over 90 ] year old male with history of coronary artery disease and atrial fibrillation was admitted on [2173-11-12] for acute abdominal pain which occured shortly after eating. Pain was sharp and non-radiating, localized in the right upper quadrant. His LFTs, alk phos, and bilirubin were elevated. He had never experienced pain similar to this in the past. Mr. [Known lastname 98584] [Last Name (Titles) 15797] nausea, vomiting and chest pain. He was admitted to the surgical team for further care and monitoring. Past Medical History: 1. Coronary artery disease status post CABG in [2161]. 2. Atrial fibrillation on Coumadin. 3. Vestibular schwannoma treated with chemotherapy at [Hospital 14852]. 4. History of a hiatal hernia. 5. Total radical resection of the prostate. 6. Bilateral inguinal hernia repairs Social History: The patient denies any tobacco use, but admits to occasional alcohol use. He lives alone and is retired. Family History: none Physical Exam: VIT: Temp 99.6 HR 84 sinus BP 137/62 RR 30 O2 sat 95% on 3L face mask EOMI,NC/AT, PERRL, anicteric CTAB RRR III/VI systolic murmur +BS, distended, tympanic, RUQ TTP no edema, 2+ pedal pulses foley in place Pertinent Results: [2173-11-12]: WBC-6.1 RBC-4.90 Hgb-15.7 Hct-41.7 MCV-85 MCH-31.9 MCHC-37.5* RDW-13.8 Plt Ct-149* PT-21.9* PTT-32.9 INR(PT)-3.4 Plt Ct-149* Glucose-136* UreaN-21* Creat-1.1 Na-138 K-4.4 Cl-99 HCO3-26 AnGap-17 ALT-281* AST-464* LD(LDH)-694* AlkPhos-179* TotBili-3.2* Lipase-239* Calcium-9.9 Phos-3.2 Mg-2.1 Lactate-2.7* [2173-11-16]: WBC-3.9* RBC-3.96* Hgb-12.7* Hct-34.3* MCV-87 MCH-32.1* MCHC-37.1* RDW-13.6 Plt Ct-168 [2173-11-18]: PT-15.0* PTT-29.9 INR(PT)-1.5 K-4.0 [2173-11-17]: TotBili-1.4 [2173-11-16]: Lipase-105* [2173-11-18]: Calcium-8.4 Phos-2.4* Mg-1.8 Brief Hospital Course: Mr. [Known lastname 98584] developed tachypnea in the ED and his O2 sats were in the high 80's to low 90's. He was afebrile and CXR showed no evidence of consolidation. He was given lasix and placed on oxygen. His sats improved and an abdominal CT was ordered which showed evidence of cholecystitis. GI was consulted and ERCP was performed the same day. He required 4 units FFP to correct his INR prior to procedure. There were no stones in his bile duct and a biliary stent was placed. He was trasferred to the ICU for further monitoring due to his troubles maintaining his O2 saturation. By hospital day 3, his sats improved and he was transferred to the floor. His LFTs trended down and his symptoms improved. He was started on a light diet and will be discharged to [Hospital 100] rehab when a bed is available. INR will be monitored by PCP. [Name10 (NameIs) ] has been instructed to follow up with Dr. [Last Name (STitle) 10356] in [1-15] weeks. He will also f/u with GI for a repeat ERCP and sphincterotomy in 2 weeks. Medications on Admission: plavix, trazadone, protonix, lopressor, ASA, coumadin, isosorbide, colace, senna Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): Please adjust dose based on daily INR results. Goal INR [1-14]. 11. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. 12. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 10 days. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - Acute Rehab Discharge Diagnosis: Cholecystitis Discharge Condition: Good Discharge Instructions: Please call your doctor or go to the ER if you experience any of the following: high fevers >101.5, severe pain uncontrolled by your medication, worsening nausea/emesis. Will need daily INR checks until therapeutic on a coumadin regimen. Will also need to hold ASA, plavix, and coumadin prior to ERCP. Please follow GI recommendations when appointment is made in regards to holding those medications. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 28258], MD Phone:[Telephone/Fax (1) 1387] Date/Time: [2173-12-7] 1:50 Dr. [Last Name (STitle) ] (for repeat ERCP) - Please call [Telephone/Fax (1) 2422] or [Telephone/Fax (1) 2799] for an appointment. Will need repeat ERCP in 2 weeks.	[ "427.31", "V58.61", "574.30", "576.1", "V45.81" ]	icd9cm	[ [ [] ] ]	[ "99.07", "51.87" ]	icd9pcs	[ [ [] ] ]	4380, 4453	2143, 3200	233, 269	4511, 4518	1531, 2120	4967, 5301	1284, 1290		3331, 4357		4474, 4490		3226, 3308			4542, 4944									1305, 1512																								179, 195										297, 839															861, 1145	1161, 1268
15,378	183,781	30400	Discharge summary	report	Admission Date: [2182-3-29] Discharge Date: [2182-3-30] Date of Birth: [2104-3-28] Sex: M Service: NEUROLOGY Allergies: Nitrate / Nitroglycerin Attending:[First Name3 (LF) 2569] Chief Complaint: Intracerebral hemorrhage Major Surgical or Invasive Procedure: None History of Present Illness: (history per records, patient's family) 78 year old man with history of hypertension, glaucoma, colon CA in [2177], who was last seen normal at 10 p.m. last night, and was found on the floor outside the bathroom by his wife at 4:30 a.m. today. He was apparently fine when his wife went to work at 10 p.m., but when she returned this morning he was lying on his right side and was minimally responsive. He was brought to [Hospital3 ] where his blood pressure was initially 200/100 and HR was in the 120's. He had a laceration and hematoma over his right brow and an ecchymosis over the right forearm. He reportedly did not speak, did not clearly follow a command to squeeze his daughter's hand, but kicked both legs spontaneously. He was intubated due to his mental status, received 4 mg versed and 2 mg ativan surrounding this, andthen started on propofol. Head CT revealed a left sided cerebral hemorrhage (the full study was not completed there, apparently; it was aborted when the hemorrhage was seen and the patient was transferred to [Hospital1 18]). Prior to transfer he was loaded with 1 g dilantin. Per his family Mr. [Known lastname ] had not recently been ill, and his wife did not know of any complaints of headache, visual changes, or difficulty with balance or coordination. He had been under great stress since his ex-wife passed away last week. Review of systems: No recent illness per his family. Past Medical History: Meningioma resected in [2169] Sigmoid colon CA s/p resection in [2177] Glaucoma Hypertension Hard of hearing Nephrotic syndrome Social History: Lives with his second wife, daughter-in-law (married to his son from the first marriage) has accompanied her to the ED. First wife died from cancer last week. Also has a daughter who lives in [Name (NI) 3914]. Family History: Father deceased at 41 from MI, mother deceased at 86 from stroke, has a child with MS. Physical Exam: (off propofol x 30 minutes) T 100.2 HR 80 BP 112/77 RR 23 Pulse Ox 100% General appearance: Intubated 79 year old man in NAD HEENT: hematoma over right eye, lac sewn up; c-spine collar in place. + clouding of cornea CV: Regular rate and rhythm without murmurs, rubs or gallops. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, moderately distended Extremities: no clubbing, cyanosis or edema. Ecchymosis over right forearm. Mental Status: No spontaneous eye opening, no eye opening to voice or sternal rub. Does not follow commands. Cranial Nerves: Right pupil is 2 mm and non-reactive, left is surgical. No blink to threat. +corneals. No response to nasal tickle, no spontaneous facial movement. Unable to assess for OCR's due to C-spine collar. No gag on ETT. Motor System: Flaccid tone throughout. Spontaneously flexes and extends both legs. Extensor postures upper extemities to proximal pinch and deep nailbed pressure, and triple flexes lower extremities to deep nailbed pressure. Reflexes: Deep tendon reflexes are a brisk 2+, slightly more brisk in RUE than LUE, symmetric in legs. Plantar responses are tonically extensor. No [Doctor Last Name 937]. Sensory: Response to noxious stimuli as above. Coordination, gait: Unable to assess Pertinent Results: At [Hospital3 ]: 17.1>15.6/44.7<370 PT 11.1, INR 0.84, PTT 31.7 Albumin 4.6, ALT 26, AST 22, Alk Phos 124, lipase 30 CK 67, Troponin <0.1 UA negative Serum tox negative At [Hospital1 18]: Lactate 7.1 Trop-T: 0.04 142 101 17 287 AGap=22 3.7 23 1.3 estGFR: 53/65 (click for details) CK: 159 MB: 4 Ca: 8.9 Mg: 1.7 P: 3.0 MCV 84 22.5 > 14.3 < 361 41.4 N:89.1 L:4.8 M:5.9 E:0.1 Bas:0.2 PT: 11.7 PTT: 26.0 INR: 1.0 Imaging: EKG at [Hospital3 ]: sinus PVC's, possible inferior infarct of undetermined age Head CT: 1. Large left temporal lobe intraparenchymal hematoma, with extensive surrounding edema causing mass effect, uncal herniation, and rightward shift of normally midline structures. Dilatation of the contralateral lateral ventricles indicates compression of the third ventricle secondary to uncal herniation. The large amount of edema surrounding the hemorrhage is more than would be expected for simple acute blood, and bleed from an underlying neoplasm is suspected. MRI is recommended for further evaluation. CXR: Endotracheal tube 5.3 cm above the carina. No acute cardiopulmonary process. KUB: no evidence of bowel obstruction CT c-spine: No fracture or alignment abnormality within the cervical spine. MRI brain: There is a large acute intracerebral hematoma identified in the left temporoparietal region extending to the occipital region with fluid-fluid level anteriorly. There is mass effect on the left lateral ventricle which is compressed with midline shift and subfalcine herniation. There is dilatation of the right lateral ventricle with evidence of periventricular edema, consequent to subfalcine herniation. In addition, there is a left-sided uncal herniation seen with deformity of the brainstem. No evidence of brainstem hemorrhage is identified. There is surrounding edema seen to the hematoma. Following gadolinium, no definite enhancement is identified in the region of hematoma or in the surrounding brain. At the craniocervical junction, the tonsils are approximately 8 mm below the level of foramen magnum due to mild tonsillar herniation. IMPRESSION: Large intraparenchymal hematoma with fluid-fluid level in the left temporoparietal region with surrounding edema. Subfalcine herniation from left to right with midline shift and left-sided uncal herniation with displacement of the brain stem without evidence of brainstem hemorrhage. No evidence of abnormal enhancement to indicate an associated mass. However, due to large size of hematoma, an underlying mask or an abnormality could not be completely excluded and followup study is recommended. MRA OF THE HEAD: The head MRA demonstrates somewhat tortuous intracranial arteries. There is anterior displacement of the left middle cerebral artery which is secondary to the large hemorrhage seen in the left temporal region. There is also medial displacement of the left posterior cerebral artery secondary to uncal herniation. IMPRESSION: No evidence of vascular occlusion. Vascular displacement due to intracerebral hematoma as described above. Head CT: 1. Slightly increased midline shift and signs of worsenign subfalcine and uncal herniation. Increased right ventricular size and periventricular edema. Brief Hospital Course: 78 year old man found unresponsive at home this morning, with large left parieto-occipital hemorrhage, with 9 mm midline shift and impending uncal herniation. On exam, patient had no eye opening to noxious stimuli. R-pupil was sluggishly reactive, left (s/p iridectomy), some spontaneous swallowing noted. B/l corneals present. Feeble extensor response on left arm, b/l triple flexion in both Lower extremities. The most likely etiology was amyloid angiopathy, although given the extensive edema an underlying mass was also possible. Patient's labs were concerning for sepsis, although there was no clear source. His prognosis for meaningful recovery was grim. This was conveyed to his wife, son and daughter-in-law, and then daughter and her husband. [Name (NI) ] was made DNR (no CPR, no cardioversion). Patient was admitted to the Neurology ICU. He was given Mannitol 50 g then 25 g q6h. HOB at 30 degrees and performed Q1h neuro checks. He was kept nothing per mouth and given 50cc/hr NS. Continued phenytoin and checked a level which was therapeutic. He was started on Vanc, ceftriaxone and flagyl for possible sepsis and urinanalyises were repeated due to contamination. Chest x-ray was negative for an acute cardiopulmonary process. Blood cultures were pending. KUB was negative for obvious obstruction or perforation. Liver function tests were within normal limits as well as lipase. Amylase was slightly elevated. Telemetry was continued and patient was ruled out for myocardial infarction. Insulins sliding scale and tylenol as needed to keep euglycemic and euthermic. Protonix and pneumoboots for GI and DVT prophylaxis. MRI brain was obtained did not show enhancing lesion but could not exclude underlying mass given the extent of the hemorrhage. A repeat head CT the following morning showed worsening subfalcine and uncal herniation with increased associated edema. Patient's clinical exam was also worsened fixed right pupil and decreased movement in his extremities. Team reconvened with the family to share the results from overnight. Family (HCP) subsequently made patient's code status comfort measure only. Patient expired shortly thereafter from respiratory failure. Medications on Admission: Lisinopril 10 mg daily Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Left parieto-occipital hemorrhage Uncal herniation Respiratory failure Discharge Condition: Deceased [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575] Completed by:[2182-3-31]	[ "401.9", "V10.05", "431" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]	9170, 9179	6850, 9067	310, 316	9293, 9443	3592, 4130		2192, 2281		9141, 9147		9200, 9272		9093, 9118												2296, 2735																			1748, 1783					246, 272										344, 1728	2862, 3573				6674, 6827	6232, 6665					2750, 2846				1805, 1943	1959, 2176
8,887	170,663	48684	Discharge summary	report	Admission Date: [2175-5-8] Discharge Date: [2175-5-11] Date of Birth: [2105-3-21] Sex: F Service: BLUE SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 70 year-old female with a history of a colon cancer and adrenal cancer with metastases to the liver presenting for right hepatic resection, exploratory laparotomy, cholecystectomy. The patient had a mass noted on studies. She denies any chest pain, problems with shortness of breath or her lungs. PAST MEDICAL HISTORY: 1. Adrenal cancer with metastases to the liver. 2. Colon cancer. PAST SURGICAL HISTORY: Colon resection in [2169], left adrenalectomy in [2157]. Status post open reduction and internal fixation of the left patella in [2157]. Arthroscopy of the left knee in 11/95 and parathyroid dissection in [2167]. ALLERGIES: No known drug allergies. MEDICATIONS AT HOME: 1. Dexamethasone 500 mg b.i.d. 2. Florinef 100 mg b.i.d. 3. Tylenol prn. 4. Multivitamins and vitamin E. PHYSICAL EXAMINATION: The patient was in no acute distress. Afebrile and vital signs were stable. Clear to auscultation. Regular rate and rhythm. Abdomen soft, nontender. No hepatomegaly noted. HOSPITAL COURSE: She underwent right hepatic lobectomy and a cholecystectomy and tolerated the procedure without complications. In the PACU the patient was noted to be over sedated. She was felt to receive perhaps too much narcotics. This resolved shortly thereafter and the patient continued to do well with only small doses of pain medication. The patient was able to tolerate regular diet on postoperative day number two and had good pain control on oral medications, ambulating well and tolerating a regular diet. By postoperative day number three she was felt to be ready for discharge to home. The patient can follow up with Dr. [Last Name (STitle) ] on [5-17] and the patient is to empty and record the output of her JP. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSIS: Status post right hepatic lobectomy, and cholecystectomy. DISCHARGE MEDICATIONS: 1. Florinef 100 mg b.i.d. 2. Dexamethasone .5 mg tablet b.i.d. 3. Colace 100 mg po b.i.d. 4. Percocet one to two tablets q 4 to 6 hours prn pain. 5. Tylenol one to two tablets q 4 to 6 hours as needed. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], M.D.,Ph.D. 02-366 Dictated By:[Name8 (MD) 5915] MEDQUIST36 D: [2175-5-11] 12:21 T: [2175-5-11] 14:05 JOB#: [Job Number 102378] cc:[Last Name (NamePattern4) 102379]	[ "V10.88", "V10.05", "197.7", "574.10", "276.2", "E935.8", "V45.79", "433.30" ]	icd9cm	[ [ [] ] ]	[ "50.3", "51.22", "88.74" ]	icd9pcs	[ [ [] ] ]									2111, 2616		2029, 2088			1222, 1947						895, 1005				604, 874														1028, 1204																					173, 490															512, 580		1972, 2008
60,582	189,944	33795	Discharge summary	report	Admission Date: [2177-11-20] Discharge Date: [2177-12-4] Date of Birth: [2137-10-7] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2290] Chief Complaint: thrombocytopenia Major Surgical or Invasive Procedure: Central Line placement Plasmapharesis History of Present Illness: EAST HOSPITAL MEDICINE ATTENDING ADMISSION NOTE Date: [2177-11-21] Time: 19:21 PCP: [Name10 (NameIs) ],[Name11 (NameIs) ]: [Telephone/Fax (1) 22245] The patient is a 40-year-old woman (PA here at [Hospital1 ]) h/o hypothyroidism and migraines, who presented at [Hospital3 ] due to 5 days of malaise, nonspecific abdominal pain, rash on legs and nausea. She was found there to have petechiae on her legs, a hematocrit of 18 and platelets of less than 5 and was sent to [Hospital1 18] ER for further evaluation. In ER: VS: 98.1 96 118/87 18 95% RA Studies: head CT w/o: wnl; CXR: unremarkable Fluids given: NS 1L Meds given: 2U PRBCs, Magnesium Sulfate 2g IV x 1, Prochlorperazine 10mg IV x 1, metoclopramide 5mg IV x 1 Consults called: Hem/Onc: Initail plan for a BM evaluation in am given concern for hematologic malignancy, but upon further review of smear, felt diagnosis is more consistant with TTP. VS prior to transfer to the ICU: 98.6 99/48 (due to altered mental status in the ED, she was transtered to the ICU from the ER. In ICU: Pt was started on plasmapheresis therapy on [2177-11-20] and her cbc counts have been trending up. Her altered mental status has improved, her platelets trending up to 20K's and Hg/hct to 7.1/19.4. Pt remained stable since she arrived to the ICU and was transfered to the floor this evening. On the floor, she reports continued nausea and a headache. She describes the headache as located in her left frontal region. She denies lacrimation, rhinorrhea, visual changes, aura or other associated symptoms. Review of Systems: (+) Per HPI (-) Denies night sweats, recent weight loss or gain. Denies visual changes, rhinorrhea, congestion or sore throat. Denies chest pain or tightness, palpitations, orthopnea, dyspnea on exertion. Denies cough, shortness of breath, wheezes or pleuritic pain. Denies diarrhea, constipation, BRBPR, melena. No dysuria, urinary frequency. Denies arthralgias or myalgias. No numbness/tingling or muscle weakness in extremities. No feelings of depression or anxiety. All other review of systems negative. Past Medical History: hypothyroidism migraines Social History: Social History: Cardiac surgery PA at [Hospital1 18]. No tobacco. Rare ETOH use. Family History: Family History: No known history of hematologic malignancies. Physical Exam: VS: 97.8 132/94 72 18 100%4L GEN: Alert and oriented to person, place and situation; no apperent distress HEENT: no trauma, pupils round and reactive to light and accomodation, no LAD, oropharynx clear, no exudates CV: regular rate and rhythm, no murmurs/gallops/rubs PULM: clear to auscultation bilaterally, no rales/crackles/rhonchi GI: soft, non-tender, non-distended; no guarding/rebound EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV present NEURO: CN II-XII intact, [5-14] motor function globally, no sensory loss DERM: petechial rash on legs bilaterally; right chest IV (3 ports) in place Pertinent Results: [2177-11-20] 01:45AM WBC-11.5* RBC-1.97* HGB-6.2* HCT-16.7* MCV-85 MCH-31.1 MCHC-36.7* RDW-17.0* [2177-11-20] 01:45AM NEUTS-83.2* BANDS-0 LYMPHS-14.2* MONOS-2.1 EOS-0.2 BASOS-0.3 [2177-11-20] 01:45AM I-HOS-SMEARS [Location (un) 109] [2177-11-20] 01:45AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-2+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-2+ OVALOCYT-OCCASIONAL TARGET-OCCASIONAL ACANTHOCY-1+ [2177-11-20] 01:45AM PLT SMR-RARE PLT COUNT-7* [2177-11-20] 01:45AM PT-12.0 PTT-23.5 INR(PT)-1.0 [2177-11-20] 01:45AM FIBRINOGE-331 [2177-11-20] 01:45AM GLUCOSE-210* UREA N-31* CREAT-1.3* SODIUM-138 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-20* ANION GAP-18 [2177-11-20] 02:07AM HGB-5.7* calcHCT-17 [2177-11-20] 02:07AM K+-4.3 [2177-11-20] 03:03AM D-DIMER-2863* [2177-11-20] 01:45AM ALT(SGPT)-48* AST(SGOT)-69* LD(LDH)-1120* ALK PHOS-85 TOT BILI-2.4* [2177-11-20] 01:45AM TOT PROT-5.9* ALBUMIN-3.8 GLOBULIN-2.1 CALCIUM-9.0 PHOSPHATE-5.3* MAGNESIUM-1.5* URIC ACID-4.4 [2177-11-20] 01:45AM HAPTOGLOB-<5* ECG: Sinus tachycardia. Low inferior lead T wave amplitude is non-specific and may be within normal limits. No previous tracing available for comparison. Head CT w/o: Wet Read: [First Name9 (NamePattern2) 68115] [Doctor First Name ] [2177-11-20] 2:49 AM No acute intracranial process. CT has limited sensitivity for the detection of acute infarction and MR can be obtained as clinically indicated. pCXR: FINDINGS: Normal lung volumes. No pneumothorax, no pleural effusions. No focal parenchymal opacity suggesting pneumonia. Normal size of the cardiac silhouette, normal hilar and mediastinal contours. Head CT: IMPRESSION: No acute intracranial process. Note that CT has limited sensitivity for the detection of acute infarction, and if of clinical concern, MR can be obtained if clinically indicated. The study and the report were reviewed by the staff radiologist. [2177-11-20] 06:45AM PT-12.4 PTT-24.4 INR(PT)-1.0 [2177-11-20] 06:54AM LACTATE-3.7* [2177-11-20] 06:54AM COMMENTS-GREEN TOP [2177-11-20] 07:30AM BONE MARROW [Doctor Last Name ]-G-DONE IRON-DONE [2177-11-20] 09:50AM FIBRINOGE-312 [2177-11-20] 09:50AM PT-12.5 PTT-25.8 INR(PT)-1.1 [2177-11-20] 09:50AM PLT COUNT-53# [2177-11-20] 09:50AM WBC-6.9 RBC-2.48 HGB-7.2* HCT-20.4* MCV-82 MCH-29.1 MCHC-35.4* RDW-16.2* [2177-11-20] 09:50AM HCG-<5 [2177-11-20] 09:50AM CALCIUM-8.4 PHOSPHATE-3.2# MAGNESIUM-1.8 [2177-11-20] 09:50AM GLUCOSE-178* UREA N-31* CREAT-1.3* SODIUM-140 POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15 [2177-11-20] 11:26AM freeCa-1.04* [2177-11-20] 11:26AM LACTATE-3.0* [2177-11-20] 11:26AM TYPE-[Last Name (un) ] PH-7.48* [2177-11-20] 05:31PM PLT COUNT-29* [2177-11-20] 05:31PM WBC-6.1 RBC-2.30* HGB-6.9* HCT-19.2* MCV-83 MCH-29.9 MCHC-35.9* RDW-16.9* [2177-11-20] 10:10PM PLT COUNT-23* [2177-11-20] 10:10PM WBC-7.0 RBC-2.44* HGB-7.4* HCT-20.4* MCV-84 MCH-30.3 MCHC-36.2* RDW-17.4* [2177-11-20] 10:10PM ALT(SGPT)-39 AST(SGOT)-46* LD(LDH)-622* TOT BILI-1.5 [2177-11-20] 10:10PM BLOOD WBC-7.0 RBC-2.44* Hgb-7.4* Hct-20.4* MCV-84 MCH-30.3 MCHC-36.2* RDW-17.4* Plt Ct-23* [2177-11-21] 04:26PM BLOOD WBC-10.5 RBC-2.61* Hgb-7.7* Hct-21.9* MCV-84 MCH-29.7 MCHC-35.3* RDW-18.1* Plt Ct-32* [2177-11-23] 06:00AM BLOOD WBC-10.3 RBC-2.33* Hgb-7.1* Hct-19.9* MCV-86 MCH-30.5 MCHC-35.7* RDW-18.9* Plt Ct-102# [2177-11-23] 06:00AM BLOOD Glucose-131 UreaN-15 Creat-1.0 Na-143 K-3.5 Cl-101 HCO3-33* AnGap-13 [2177-11-21] 08:18AM BLOOD ALT-74* AST-85* LD(LDH)-657* TotBili-2.0* [2177-11-22] 05:56AM BLOOD ALT-129* AST-109* LD(LDH)-467* AlkPhos-69 TotBili-2.3* [2177-11-23] 06:00AM BLOOD ALT-67* AST-36 LD(LDH)-280* [2177-11-23] 06:00AM BLOOD ADAMTS13 EVALUATION-PND [2177-11-20] 11:42AM BLOOD ADAMTS13 EVALUATION-PND [2177-12-4] 11:15AM BLOOD WBC-13.2* RBC-3.25* Hgb-10.1* Hct-30.3* MCV-93 MCH-31.2 MCHC-33.4 RDW-19.1* Plt Ct-171 [2177-11-29] 04:52AM BLOOD Glucose-98 UreaN-18 Creat-0.8 Na-141 K-3.4 Cl-104 HCO3-29 AnGap-11 [2177-12-4] 05:30AM BLOOD LD(LDH)-136 [2177-11-29] 04:52AM BLOOD Calcium-9.2 Phos-3.8 Mg-1.7 Abdomen Ultrasound ([2177-11-21]): 1. Increased hepatic echotexture, findings likely on the basis of fatty deposition. Please note that more advanced forms of hepatic disease such as fibrosis and cirrhosis cannot definitively be excluded. 2. Small right pleural effusion. 3. Normal son[Name (NI) 493] appearance of the gallbladder. Brief Hospital Course: 40F with a past medical history of hypothyroidism and migraines who presented to an outside hospital with five days of malaise, nonspecific abdominal pain, rash on her legs as well as nausea. She was noted to have altered mental status and was ultimately diagnosed with TTP. She was treated with steroids and plasmapheresis with eventual improvement in her platelets. 1. Thrombotic Thrombocytopenic Purpura: Constellation of [Doctor First Name ], thrombocytopenia, acute renal failure, and altered mental status was consistant with TTP. Pt was started on high dose prednisone (80 mg daily) and plasmapheresis therapy on [2177-11-20] and her counts initially trended up. Her altered mental status and mild renal failure improved. However, her platelets started decreasing on [2177-11-24]. They nadired again at 71. HIT antibody was negative and DIC labs were also negative. Ultimately, plasmapheresis exhcnage was increased and her platelets began increasing. Her platelets were greater than 150 as of [12-2] and remained greater than 150 through the remainder fo her hospital course. Her last plasmapheresis was on [2177-12-3]. ADAMST13 was sent and consistent with TTP. She was discharged on 80 mg of Prednisone daily as well as Bactrim prophylaxis for PCP. [Name10 (NameIs) ] will have her blood work checked on Friday ([12-5]) and Monday ([12-8]). She has follow-up scheduled with hematology on [12-10]. . 2. Headache - She had two migraine headaches that were responsive to treatment with imitrex. . 3. Hypothyroidism, depression - stable, home regimen continued. . Code: Full (discussed with patient) Medications on Admission: acetaminophen-codeine 300 mg-30 1-2 tabs po q6h prn pain imitrex 50 mg 1 po prn levothyroxine 112 mcg 1 po daily methylprednisone 4 mg po daily relpax 40 mg 1 po prn migraine yaz 28 1 po daily Discharge Medications: 1. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. folic acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. prednisone 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily) for 2 weeks. Disp:56 Tablet(s) Refills:0 7. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (TU,TH,SA). Disp:16 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: TTP Migraine Headache Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with Thrombocytopenia Thrombotic Purpura. This was treated with plasmapharesis (last treatment [12-3]) and steroids with resolution of the hemolysis and normalization of the platelet count. Your blood count was 30.3 on the morning of discharge after receiving two units of packed red blood cells. Your platelets were 171 on th morning of discharge. You were seen by hematology consult. You had occasional migraine headaches which resonded to sumatriptan single dose. Followup Instructions: Department: INFUSION/PHERESIS UNIT When: FRIDAY [2177-12-5] at 11:15 AM [Telephone/Fax (1) 14067] Building: GZ [Hospital Ward Name ] BUILDING (FELBEERG/[Hospital Ward Name ] COMPLEX) [Location (un) ] Campus: EAST Best Parking: Main Garage Department: INFUSION/PHERESIS UNIT When: MONDAY [2177-12-8] at 10:15 AM [Telephone/Fax (1) 14067] Building: GZ [Hospital Ward Name ] BUILDING (FELBEERG/[Hospital Ward Name ] COMPLEX) [Location (un) ] Campus: EAST Best Parking: Main Garage Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [2177-12-10] at 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 13999], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "584.9", "244.9", "311", "446.6", "346.90", "789.00", "787.01" ]	icd9cm	[ [ [] ] ]	[ "41.31", "99.71", "38.97" ]	icd9pcs	[ [ [] ] ]	10603, 10609	8020, 9674	333, 373	10675, 10675	3399, 5092	11343, 12203	2696, 2743		9917, 10580		10630, 10654		9700, 9894			10826, 11320									2758, 3380																			2005, 2514					277, 295										401, 1986					5101, 7997						10690, 10802				2536, 2562	2594, 2664
25,255	137,925	7245	Discharge summary	report	Admission Date: [2200-11-21] Discharge Date: [2200-11-27] Date of Birth: [2136-11-27] Sex: M Service: CARD [Doctor First Name 147] HISTORY OF PRESENT ILLNESS: Mr. [Known lastname ] is a 63 year old male with a past medical history significant for long standing diabetes mellitus who is status post renal and pancreas transplant in [2190]. The patient also had a myocardial infarction in [2190] as well as a percutaneous transluminal coronary angioplasty and stent placement within a right coronary artery in [2195]. A cardiac catheterization performed at that time showed 50% left anterior descending lesion, 70% obtuse marginal lesion and an ejection fraction of 51%. Recently, however, the patient started to have some pressure in his arms and chest when he ambulated up any type of incline. According to a report, the patient had a stress echocardiogram performed in [State 108] which showed no change from his previous findings. He was, at that point, placed on an increased dose of Lopressor. Over the last few months, however, the patient reports increasing frequency of chest pressure with activity. The patient denies any chest pain at rest. He also denies claudication, orthopnea, edema, paroxysmal nocturnal dyspnea or lightheadedness. Prior to admission, the patient had a cardiac catheterization performed on [2200-11-14]. That cardiac catheterization revealed three vessel coronary artery disease. His left main coronary artery had no angiographic evidence of stenosis. The left anterior descending artery had a focal 90% stenosis in the mid segment. The circumflex system had luminal irregularities with two 90% stenoses in the large first obtuse marginal. The right coronary artery had an 80% ostial stenosis. Ejection fraction was not assessed at that time. PAST MEDICAL HISTORY: 1. History of type 1 diabetes mellitus status post kidney and pancreas transplant. 2. Hypertension. 3. Diabetic retinopathy. 4. Sleep apnea. 5. Foot ulcer. PAST SURGICAL HISTORY: 1. Renal and pancreas transplant in [2190] complicated by postoperative wound dehiscence and pancreatic leak. 2. Recent chest cyst removed. ALLERGIES: Penicillin. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg p.o. q. day. 2. Zantac 150 mg p.o. twice a day. 3. Lopressor 50 mg q. a.m. and 25 mg q. p.m. 4. Norvasc 5 mg q. day. 5. Colace 100 mg p.o. q. day. 6. Cyclosporin 200 mg p.o. q. a.m. and 150 mg p.o. q. p.m. 7. Double strength Bactrim every Monday, Wednesday and Friday. 8. Prednisone 5 mg p.o. q. day. 9. Imuran 25 gm p.o. q. day. SOCIAL HISTORY: The patient is married. There is no history of tobacco or alcohol abuse. LABORATORY: On admission, hematocrit 36.8, white blood cell count 4.4, platelets 187. Glucose 69, BUN 36, creatinine 1.3, sodium 139, potassium 4.9. Albumin 3.5. EKG performed on [2200-11-14] showed sinus bradycardia with a probable anteroseptal infarction with undetermined age, left ventricular hypertrophy but no change since previous EKG. PHYSICAL EXAMINATION: In general, alert and oriented middle aged male in no apparent distress. Vital signs are temperature 98.2 F.; heart rate 76; blood pressure 139/69; respiratory rate 18; 95% on room air. HEENT examination within normal limits. Heart examination regular rate and rhythm; no murmurs. Chest clear to auscultation bilaterally. Abdomen soft, nontender, nondistended. Extremities warm and well perfused; no evidence of edema. Pulses present bilaterally upper and lower extremity. Neurologic examination grossly intact. SUMMARY OF HOSPITAL COURSE: Prior to admission, the patient underwent a cardiac catheterization which demonstrated three vessel coronary artery disease. At that time, it was decided that a surgical intervention would be the best approach. The patient was admitted to Cardiac Surgery. On [2200-11-21], the patient underwent coronary artery bypass graft times three; left internal mammary artery to left anterior descending; saphenous vein graft to obtuse marginal; saphenous vein graft to patent ductus arteriosus. The patient tolerated the procedure well. There were no complications. Please see the full operative report for detail. The patient was then transferred to the Intensive Care Unit in fair condition. He remained intubated. The patient remained in sinus rhythm with occasional unifocal premature ventricular contractions. His urine output was adequate. The patient was extubated on postoperative day zero. He tolerated the extubation well. He showed good oxygenation levels. The Renal Service was consulted given the history of the renal/pancreas transplant. This service followed the patient throughout his hospitalization. The patient was continued on his immunosuppressive regimen. His hematocrit on postoperative day one was 25.8. He originally required some Neo-synephrine. The patient received perioperative Vancomycin. His blood sugars were noted to be slightly elevated and he was maintained on insulin and titrated appropriately. The patient was tolerating the diet well. The chest tube was removed on postoperative day one. His urine catheter was removed on postoperative day two. The patient received Lopressor. Physical Therapy was consulted which followed the patient throughout his hospitalization. The patient was eventually cleared by Physical Therapy to go home. His blood pressure and heart rate remained stable. He was maintained on Bactrim prophylaxis as preoperatively. His incision remained clean, dry and intact. The patient was transferred to the Floor on postoperative day three in stable condition. His hematocrit on postoperative day four was 27 with creatinine of 1.6, which is basically his baseline. The patient remained afebrile. He was ambulating without assistance. The patient was discharged to home on [2200-11-27]. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home. DISCHARGE DIAGNOSES: 1. Coronary artery disease and unstable angina status post a coronary artery bypass graft times three. 2. Hypertension. 3. Congestive heart failure. 4. Coronary artery disease. 5. Noninsulin dependent diabetes mellitus. 6. Diabetic retinopathy. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q. day. 2. Zantac 150 mg p.o. twice a day. 3. Lopressor 50 mg p.o. q. a.m. and 25 mg p.o. q. p.m. 4. Norvasc 5 mg p.o. q. day. 5. Percocet one to two pills p.o. q. four to six hours p.r.n. pain. 6. Colace 100 mg p.o. twice a day p.r.n. constipation. 7. Cyclosporin (Neoral) 200 mg p.o. q. a.m. and 150 mg p.o. q. p.m. 8. Double strength Bactrim every Monday, Wednesday and Friday, one tablet p.o. 9. Prednisone 5 mg p.o. q. day. 10. Imuran 25 mg p.o. q. day. 11. Lasix 20 mg p.o. twice a day times five days. 12. Potassium chloride 20 mEq p.o. twice a day times seven days. DISCHARGE INSTRUCTIONS: 1. The patient is to see his surgeon, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in approximately four weeks. 2. The patient is to see his primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Name (STitle) 805] in approximately one to two weeks. 3. The patient is to see his Cardiologist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 26809], on approximately three to four weeks. 4. The patient is to see his nephrologist in approximately two to three weeks. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Last Name (NamePattern1) 1741] MEDQUIST36 D: [2200-11-28] 15:05 T: [2200-11-28] 16:49 JOB#: [Job Number 26810]	[ "V42.0", "458.2", "362.01", "411.1", "V42.83", "414.01", "250.51", "780.57", "428.0" ]	icd9cm	[ [ [] ] ]	[ "36.15", "36.12", "93.90", "89.68", "39.61" ]	icd9pcs	[ [ [] ] ]	5971, 5978							5999, 6251	6274, 6881				2258, 2616			6905, 7740								2059, 2232											3635, 5913			3085, 3605																					198, 1852															1874, 2036	2634, 3061	5939, 5946
2,076	178,419	7113	Discharge summary	report	Admission Date: [2198-5-2] Discharge Date: [2198-5-16] Date of Birth: [2133-11-21] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5644] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: 1. bronchoscopy with bronchial brushings and biopsies 2. pleuroscopy with pleural biopsies 3. placement of chest tube 4. pleurodesis x2 History of Present Illness: Pt is a 64y/o M with tobacco history and asbestos exposure who has noticed increasing SOB since [Month (only) 956]. He noted that his SOB started as he was going upstairs to the second level of his home, when he would feel winded. At around the same time, a cough developed, which was often productive of clear or yellow sputum in the morning. He denies bloody sputum. He notes that his SOB and cough worsened over the next few months. In [Month (only) 547], he was seen for a stress test and a CXR was performed, which showed the pleural effusion. This was tapped, which yielded about 2 L and pt noted symptomatic improvement. Cytology was negative; effusion was exudative. Pt was admitted for bronchoscopy because of the concern for the RUL mass seen and because of the recurrent R pleural effusion. Denies fevers, chills, chest pain, diaphoresis. SOB feels like breathing more frequently, more shallowly, with some wheezing. SOB worse with sitting up, and with any movement or exertion. Past Medical History: 1. dyspnea x 6 months 2. diabetes mellitus 3. coronary artery disease s/p CABG [2190], stent [2192], positive stress test 4. hypogonadism 5. h/o urinary retention in setting of UTI 6. recurrent R pleural effusion 7. h/o surgical removal of kidney stone in [2168] 8. Dupuytren's contractures Social History: Pt is a real estate executive for a restaurant company. Lives with his wife, has 4 children. Smoked 2.5ppd x22 years, quit in [2167]. Asbestos exposure. No pets. Denies alcohol or recreational drug use. Family History: M - DM, reproductive cancer, ? [Last Name ] problem F - lost at sea in [2152] no other cancer or asthma Physical Exam: VS: Tm 98.6 Tc 98.0 133/52 85 26 93% 3L NC Gen: elderly male, somewhat rapid breathing with talking, frequent shallow dry coughing, does not appear uncomfortable HEENT: PERRL, EOMI, OP clear, MMM, tender anterior cervical LAD about 1cm in size, 2 cm smooth mobile mass on R posterior neck CV: RRR, nl S1/S2, no murmurs appreciated Pulm: dullness to percussion on R side with tubular breath sounds, decreased breath sounds on R; on L, end-expiratory wheezes over area of lung [2-1] way up; coarse breath sounds diffusely on L Abd: soft, mildly distended, nontender, +BS, no masses Ext: no edema Neuro: A&O x3, 5/5 strength in all 4 extremities Pertinent Results: Admission labs: CBC: WBC-17.6# RBC-4.10 HGB-12.4* HCT-36.4* MCV-89 MCH-30.2 MCHC-34.0 RDW-13.6 NEUTS-78* BANDS-11* LYMPHS-4* MONOS-4 EOS-0 BASOS-1 ATYPS-2* METAS-0 MYELOS-0 HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL PLT COUNT-624* coags: PT-13.2 PTT-24.1 INR(PT)-1.2 electrolytes: GLUCOSE-206* UREA N-15 CREAT-0.7 SODIUM-137 POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-24 ANION GAP-16 CALCIUM-9.3 PHOSPHATE-2.6* MAGNESIUM-1.5* chest CT [5-2]: IMPRESSION: 1) Again seen is a large right pleural effusion. Additionally, there is persistent narrowing of the right main stem bronchus with associated postobstructive consolidation, which appears similar to the prior study. 2) Cholelithiasis. chest/abdomen/pelvis CT: [5-9]: IMPRESSION: 1) Narrowing of the right main stem bronchus, unchanged, however, complete consolidation of the inferior segments of the right lower lung lobe. Improved aeration of the right upper lobe. 2) Interval placement of right-sided chest tube with decreased right pleural fluid. New low-density loculations within the remaining right pleural fluid. New small right hydropneumothorax. 3) No foci of disease within the abdomen or pelvis. 4) Cholelithiasis without evidence for cholecystitis. head CT: [5-9]: no evidence of intracranial mets [5-10] LE Dopplers: IMPRESSION: No evidence of DVT. [2198-5-10] bone scan: IMPRESSION: Tracer uptake in the right ribs compatible with prior trauma. No evidence of metastatic disease. CXR: IMPRESSION: Right-sided post-procedure change and slight enlargement of right pleural effusion. No evidence of pneumothorax. Pathology: [5-2] bronchial washings: Atypical glandular-apearing epithelial cells, cannot exclude non-small cell carcinoma. [5-4] pleural biopsy: poorly differentiated adenocarcinoma; the tumor cells show staining for cytokeratin-7, but no staining for cytokeratin-20, TTF-1, prostate-specific antigen, or prostatic acid phosphatase. This immunophenotype is not specific for any one site of origin. However, the histologic features of this tumor and this immunophenotype could be consistent with a lung origin. Absence of staining for the prostate markers and the cytokeratin-7 positivity rule out a prostatic origin. The histologic appearance makes a gastrointestinal or pancreatico-biliary origin unlikely. [5-4] pleural fluid, cell block: adenocarcinoma Brief Hospital Course: 1. adenocarcinoma - Pt had recurrent right pleural effusion and a mass seen on CT scan; given his past history of smoking and asbestos exposure, concern was clearly for malignancy. Pt underwent bronchoscopy with BAL. Bronchial biopsies were consistent with well-differentiated adenocarcinoma. As pt had recurrent R pleural effusion, a pleuroscopy was performed, which showed studding of parietal pleura with small masses, which were biopsied and found to be consistent with poorly differentiated adenocarcinoma. Pt underwent talc pleurodesis; the first attempt was unsuccessful, so a second trial of talc pleurodesis was performed, and the chest tube had little output after [2-1] days and was successfully removed. Hem/onc was consulted as the biopsy results returned positive for carcinoma. Staging CT scans and a bone scan were performed, which showed no evidence of metastasis. As pt had an acute infectious process, namely the pneumonia discussed below, chemotherapy was not an option while in the hospital. XRT was consulted, as well, with the thought that perhaps tumor debulking would help to relieve a postobstructive pneumonia. However, with further analysis of the CT scan, it was felt that inflammation from the VATS procedure and inflammation from the pneumonia were the causes of obstruction, and XRT would not improve the situation, and may in fact be harmful. At the time of discharge, pt had appointments in place to see hem/onc and XRT the following day. 2. postobstructive pneumonia - Pt completed a 7 day course of levo/flagyl but continued to have increased O2 requirements (up to 10L NC, satting in the low 90s) and was febrile. A repeat chest CT scan showed increased consolidation in the RLL. Pt was therefore placed on Zosyn/vanco, with a plan for a 2-week course total. He was also treated with albuterol/atrovent nebs while in the hospital, and was discharged with MDIs. Further, pt had question of O2 requirement overnight, though physical therapy documented sats in the low 90s on room air during the daytime. Pt had home O2 delivered prior to discharge. He had a PICC placed for the rest of his course of Zosyn/vanco. Pt's Tmax in the 24 hours prior to discharge was <100.0. 3. diabetes mellitus type 2, poorly controlled - Pt was continued on rosiglitazone, metformin, and glyburide. Metformin was held prior to CT scans. Pt was also placed on RISS, and fingersticks were checked 4 times daily. Pt was noted to have increased hyperglycemia, requiring up to 20 units glargine, thought to be due at least partially to his acute infection, as well as due to the holding of metformin. He was discharged on oral hypoglycemics and instructed to check his fingersticks and call his PCP [Last Name (NamePattern4) ] >350. 4. CAD s/p CABG and stent - Pt was continued on atenolol, statin, and ACE I. Pt will need to be restarted on aspirin as an outpatient. 5. Code - full at this time Medications on Admission: atorvastatin atenolol lisinopril aspirin tamsulosin prilosec metformin glyburide rosiglitazone B12 Discharge Medications: 1. Home oxygen Continuous 2L Nasal cannula For portability pulse-dose system 2. Atorvastatin Calcium 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atenolol 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Rosiglitazone Maleate 4 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Glucosamine 1,000 mg Tablet Sig: One (1) Tablet PO qd () as needed for oa. 11. Vancomycin HCl in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q12H (every 12 hours) for 7 days. Disp:14 gram Refills:0 12. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 7 days. Disp:21 Recon Soln(s) Refills:0 13. Metformin HCl 1,000 mg Tablet Sig: One (1) Tablet PO qAM. 14. Metformin HCl 1,000 mg Tablet Sig: 1.5 Tablets PO qPM. 15. Combivent 103-18 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours. Disp:1 inhaler Refills:2 16. spacer for metered dose inhaler Disp: 1 Refills: 2 Discharge Disposition: Home With Service Facility: Critical Care Discharge Diagnosis: Primary: 1. adenocarcinoma, likely of lung 2. post-obstructive pneumonia Secondary: 1. diabetes mellitus type 2 2. coronary artery disease Discharge Condition: stable, tolerating po, RA sat 87-92% ambulating Discharge Instructions: Please call your PCP with any increased shortness of breath, chest pain, more sputum production, or if your glucose is consistently >300. Please keep all of your appointments and take all of your medications. You may resume your metformin when you return home and you should check your fingersticks two to three times per day and call your PCP if they are elevated. Followup Instructions: Provider: [Name10 (NameIs) ],[First Name3 (LF) ] MULTI-SPECIALTY MULTI-SPECIALTY THORACIC UNIT-CC9 Where: CLINICAL CTR. - 9TH FL. MULTI Date/Time:[2198-5-17] 3:00 Provider: [Name10 (NameIs) 2502],[Name11 (NameIs) ] HEMATOLOGY/ONCOLOGY-CC9 Where: [Hospital 4054] HEMATOLOGY/ONCOLOGY Phone:[Telephone/Fax (1) 22] Date/Time:[2198-5-17] 3:00 Provider: [Name10 (NameIs) ],[First Name3 (LF) ] MULTI-SPECIALTY MULTI-SPECIALTY THORACIC UNIT-CC9 Where: CLINICAL CTR. - 9TH FL. MULTI Date/Time:[2198-5-17] 4:00	[ "197.2", "V45.81", "162.3", "485", "250.00" ]	icd9cm	[ [ [] ] ]	[ "34.24", "33.24", "34.92", "38.93", "34.91", "34.04" ]	icd9pcs	[ [ [] ] ]	9876, 9920	5360, 8306	335, 477	10107, 10156	2899, 2899	10571, 11121	2094, 2207		8455, 9853		9941, 10086		8332, 8432			10180, 10548									2222, 2880																								276, 297										505, 1515					4187, 5337		2916, 4178								1537, 1849	1865, 2078
59,113	169,374	37831	Discharge summary	report	Admission Date: [2194-10-31] Discharge Date: [2194-11-8] Date of Birth: [2113-2-3] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2763] Chief Complaint: transfer from OSH for management of c. diff/hiv Major Surgical or Invasive Procedure: intubation bronchoscopy History of Present Illness: Mr. [Known lastname 84644] is a 81 year old male with past medical history of HIV (CD4 215 [10-31], HAART stopped [10-30]), C. Difficile infection, Chronic hepatitis B, adrenal insufficiency, MDS, and esophogitis who was transferred to [Hospital1 18] from [Hospital1 392] for management of his care. Mr. [Known lastname 84644] previously had no medical illnesses until [Month (only) 205] of this year. At that time, he presented to [Hospital6 ] with complaint of weakness. At that time, he was diagnosed with MDS and placed on steroids. He required transfusions of PRBCs and platelets as needed. Additionally, he was treated with antibiotics for fever. At the time of transfer, records are not available and history is via patient's son. [Name (NI) ] was discharged home after approx a 1 week stay only to return ~4 days later with complaint of chest pain. . Per his son, he did not suffer a heart attack, but instead was diagnosed with esophogitis by EGD. He was treated with sucralfate and lidocaine. During this hospitalization, he was diagnosed with HIV and hepatitis B (listed as chronic in transfer paperwork from [Hospital1 392]). He was not started on HAART at this time. Additionally, his son states that there was a CT Head during this admission that was consistent with a previous stroke. After discharge, Mr. [Known lastname 84644] was doing well for 1 to 2 days before developing fever, diarrhea and vomitting. . He was again admitted to [Hospital1 2177] with hypotension and had a prolonged, 5[Hospital ] hospital course. He required 2 transfers to the ICU--one for SIRS in setting of RLL infiltrate requiring vasopressors. During this admission, his steroids had been decreased, however, he developed adrenal insufficiency and required re-titration of his steroids to appropriate levels with appropriate improvement in his blood pressure. During this admission he was started on HAART and Bactrim, but developed a rash 3 days later. Bactrim was discontinued, Dapsone started instead for prophylaxis. Mr. [Known lastname 84644] was eventually discharged home on [2194-10-11] with intent to get a second opinion at [Hospital1 2025]. After arriving home, he developed worsening diarrhea and decline over a span of days. His son states he was basically non-responsive and he was taken by ambulance to [Hospital6 10353] on [2194-10-20] for evaluation. . On admission to [Hospital1 392], he was hypotensive and tachycardic. He was admitted to a partial care unit where he was resuscitated with fluids. On [2194-10-21], he was started on vancomycin and flagyl for treatment of C. Diff (unclear if he was diagnosed at [Hospital1 2177] with C. Diff). CT A/P at that time showed colitis. For his adrenal insufficiency, he had been taking Dexamethasone 1mg qam and 2mg qpm as an outpatient. He was briefly started on Florinef, however he developed anasarca and was placed back on Dexamethasone 1 mg qid with stable hemodynamics. During the course of the admission, his creatinine was noted to increase from 1.3 to 1.76. Additionally, patient became increasingly thrombocytopenic with platelets of 20 on day of transfer. Heme/Onc felt thrombocytopenia may have been due to HAART. Due to crystals in urine, renal felt HAART may account for ARF. On [10-30], HAART was discontinued in the presence of 2L positive with UOP of 4mL noted. He also had worsening anasarca. Also noted on admission to [Hospital1 392] was oral thrush for which he was treated with a 2 week course of fluconazole (possibly 3 weeks treatment). LFTs were apparently stable and hepatitis B was not considered an acute issue. . ROS: positive for edema, diarrhea, fatigue, weakness. denies headache, change in vision or hearing, sore throat, chest pain, abdominal pain, numbness in his extremities. Past Medical History: - HIV, dx ~[7-31], CD4 215 [10-31], HAART (emtricitabine-tenofivir, atazanavir, ritonavir) discontinued [10-30]. c/b esophogitis. - MDS, diagnosed [7-31] at [Hospital1 18], required PRBCs - Adrenal Insufficiency, diagnosed [8-31] - C. diff colitis, currently undergoing treatment - Hepatitis B - DM type 2 - HTN Social History: Immigrated from [Country 38213] in [2190] with permanent residency, son states his infectious workup at that time was negative. No known HIV risk factors, son not able to answer sexual history questions. No alcohol history. Started smoking at age 45, 1 ppd x 40 years. No drug history. Family History: Unknown Physical Exam: VITALS: T: 98.7 BP: 104/D HR: 80 RR: 18 O2:98 2L GENERAL: elderly male in NAD, lying in bed, responsive, anasarca. HEENT: NC/AT, PERRL, dry mucous membranes, EOMI, oropharynx clear - no visible thrush. sclera anicteric. conjunctival injection in Left eye. NECK: No LAD, no thyromegally. CHEST: inspiratory crackles at bilateral lung bases. o/w CTA bilaterally with no wheezing. CV: RRR, no m/g/r. s1 and s2. no s3 or s4. ABD: soft, mild tenderness to palpation diffusely. No guarding or rebound tenderness. No suprapubic tenderness. EXT: all 4 extremeties with generalized anasarca, in legs L>R. radial pulses difficult to palpate with edema. NEURO: Alert. CN II-XII intact. strength 4/5 in all 4 extremities. Sensation intact throughout. Gait and cerebellar function not assessed. SKIN: mottled appearance over extremities. no rashes or petechiae noted. Pertinent Results: Please see OMR for evaluation of extensive medical workup completed during patient's hospitalization. Brief Hospital Course: 82 yom with adrenal insuficiency, MDS, and new HIV diagnosis who presentwed with generalized illness and hypotension. His symptoms were thought to be due to C dif colitis initially however his hypotension was severely out of proportion to his diarrhea and did not respond adequately to fluid boluses. He was started on pressors and also given pulse dose steroids given his history of adrenal insufficiency. His mental status was poor and remained that way, he continued to do more poorly each day failing to wean off of pressors or improve his mental status. His renal function did not improve despite improved renal perfusion and patient was not a candidate for dialysis. Decision from his family was to reduce the level of care and patient was made CMO. He passed away peacefully with family at the bedside after a prolonged and unsuccessful medical evaluation to assess for factors that may be contributing to his illness. Medications on Admission: ON transfer from OSH - Bicitra 30 ML PO BID - D50W 50 mL IV prn - Decadron 1 mg PO qid - Diflucan 200mg Po qday (12 day course) - Flagyl 500 mg PO tid - Glucagon 1mg IM prn - Glutose 15g oral prn - Lactinex 1 packet TID - Prilosec 20 mg PO - Regular Insulin Sliding Scale - Vancomycin solution 125mg PO q6h Discharge Disposition: Expired Discharge Diagnosis: adrenal insufficiency myelodysplastic syndrome sepsis HIV thyrombocytopenia acute renal failure Discharge Condition: deceased [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2764] Completed by:[2195-3-26]	[ "995.92", "401.9", "276.1", "284.1", "255.41", "518.81", "573.4", "250.00", "038.9", "584.9", "238.75", "518.0", "287.5", "453.40", "276.2", "008.45", "V08", "577.0" ]	icd9cm	[ [ [] ] ]	[ "96.71", "33.24", "38.95", "39.95", "38.93", "96.04" ]	icd9pcs	[ [ [] ] ]	7280, 7289	5989, 6922	363, 388	7428, 7559	5863, 5966		4964, 4973				7310, 7407		6948, 7257												4988, 5844																								276, 325										416, 4278															4300, 4637	4653, 4948
11,885	174,078	14516+14517	Discharge summary	report+report	Admission Date: [2161-9-22] Discharge Date: [2161-9-29] Date of Birth: [2087-3-2] Sex: M Service: CSU This dictation is done for the cardiothoracic service. HISTORY OF PRESENT ILLNESS: Mr. [Name13 (STitle) ] is a 74-year-old man admitted to an outside hospital on [9-17] with a 2-week history of dyspnea on exertion and fatigue which these symptoms had increased over the previous 2-3 days prior to admission. No chest pain or associated nausea or vomiting prior to the onset of symptoms. He had exercised on a treadmill for 60 minutes per day and was able to walk up of a flight of stairs with ease. He was transferred [Hospital ] [Hospital ] [First Name (Titles) ] [Last Name (Titles) ] for cardiac catheterization which revealed three-vessel disease. He was then referred to cardiothoracic surgery for coronary artery bypass grafting. PAST MEDICAL HISTORY: Significant for CVA in [2-/2160] with residual fine motor deficit in the right hand, status post right CEA in [2-/2160], abdominal aortic aneurysm 4.5 cm by CAT scan, PVD, diabetes mellitus type 2, currently taking no medicine well controlled with exercise and diet, and status post GI bleed, hypertension and left subclavian artery stenosis. SOCIAL HISTORY: Retired engineer, widowed, lives alone. Remote tobacco use, quit 14 years ago. No alcohol use. MEDICATIONS PRIOR TO ADMISSION: Zestril 10 mg once daily, Plavix 75 mg once daily, aspirin 81 mg once daily, Lipitor 20 mg once daily, Corgard 40 mg once daily, hydrochlorothiazide 25 mg once daily. ALLERGIES: No known drug allergies. LABORATORY DATA: Prior to admission, white count 5.8, hematocrit 33.9, platelets 149, sodium 135, potassium 3.8, chloride 97, CO2 of 28, BUN 33, creatinine 1.1, glucose 126, PT 32, INR 1.1. As stated previously his cardiac catheterization showed a three-vessel disease with 60 percent LAD lesion, 50 percent left circumflex lesion and 60 percent ostial RCA lesion. Patient has reported a EF of 60 percent with trace MR and mild TR by an echo done at the [Hospital3 29718]. PHYSICAL EXAM: Neurological: Alert and oriented times three, moves all extremities, follows commands. Pulmonary: Clear to auscultation bilaterally. Cardiac: Regular rate and rhythm. Abdomen is soft, nontender, nondistended, normoactive bowel sounds. Extremities are warm. No edema. No varicosities, positive spider veins. HOSPITAL COURSE: Following cardiac cath and CT surgery consult, the patient was seen by the Stroke service to evaluate for risk of perioperative stroke and on [9-23], he was brought to the operating room where he underwent coronary artery bypass grafting. Please see the OR report for full details. In summary, the patient had a CABG times four with the LIMA to the LAD, saphenous vein graft to the RCA, saphenous vein graft to OM-3 with a jump graft to OM-2. His bypass time was 90 minutes with a cross-clamp time of 64 minutes. He tolerated the operation well, was transferred from the operating room to the cardiothoracic intensive care unit. At the time transfer, the patient was A paced at 80 beats per minute. He had a mean arterial pressure of 76 with a CVP of 15. He had propofol at 20 mcg/kg/minimal and Neo- Synephrine at 0.3 mcg/kg/hour. The patient did well in the immediate postoperative period. His anesthesia was reversed. He was weaned from the ventilator and successfully extubated however following extubation, the patient became acutely anxious and required reintubation. Following reintubation, the patient was begun on a Precedex infusion following which he his anxiety stabilized and he was able to follow commands. He was again weaned to C-PAP and the following morning successfully extubated. Throughout this period, the patient remained hemodynamically stable. On postoperative day three, the patient was noted to have periods of atrial fibrillation which were treated with beta blockers as well as IV amiodarone. Ultimately, the patient converted back to normal sinus rhythm. He remained hemodynamically stable throughout this period. On postoperative day four, the patient's temporary pacing wires were removed, his Foley catheter was removed. He was changed from IV amiodarone to oral amiodarone and he was transferred to the floor for continuing postoperative care and cardiac rehabilitation. Over the next several days, the patient had an uneventful postoperative course. His activity level was advanced with the assistance of the nursing staff as well as physical therapist and on postoperative day five, it was decided that the following day the patient would be ready for discharge to rehabilitation center. VITAL SIGNS At the time of this dictation, the patient's physical exam is as follows. Vital signs: Temperature 97, heart rate 67 sinus rhythm, blood pressure 150/76, respiratory rate 24, O2 sat 93 percent on room air. LABORATORY DATA: White count 7.9, hematocrit 31, platelets 171, PT 14, PTT 86.6, INR 1.3, sodium 141, potassium 3.5, chloride 101, CO2 of 31, BUN 32, creatinine 1.2, glucose 118. PHYSICAL EXAM: Neurologically alert and oriented times three, moves all extremities, follows commands, slight left upper extremity weakness, residual from an old CVA. Respiratory: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, S1-S2 with no murmur. Sternum is stable. Incision with Steri-Strips, open to air, clean and dry. Abdomen is soft, nontender, nondistended with normal active bowel sounds. Extremities are warm, well-perfused with one plus edema. Right leg saphenous vein graft harvest site with Steri-Strips, open to air, clean and dry. DISCHARGE MEDICATIONS: Aspirin 325 mg once daily, Colace 100 mg b.i.d., Percocet 5/325 1-2 tablets q. 4-6 hours p.r.n., Imdur 60 mg once daily, Zantac 150 mg once daily, metoprolol 50 mg b.i.d., amiodarone 400 mg b.i.d. times 1 week then 400 mg once daily times 1 week then 200 mg once daily times 1 month, captopril 25 mg t.i.d., potassium chloride 20 mEq b.i.d., Lipitor 20 mg once daily, Lasix 20 mg b.i.d. CONDITION AT DISCHARGE: Good. DISPOSITION: He is to be discharged to rehabilitation at [Location (un) 582] in [Location (un) 620]. DISCHARGE DIAGNOSES: CAD status post coronary artery bypass grafting times four with the LIMA to the LAD, saphenous vein graft to the RCA, saphenous vein graft to OM-2 with a jump to OM-3. Hypertension. Diabetes mellitus type 2. Chronic renal insufficiency. Right CEA. CVA with left sided upper extremity weakness. TURP. AAA measuring 4.5 cm. Skin cancer. PVD. FOLLOW UP: Patient is to have follow-up with Dr. [Last Name (STitle) 42883] in [2-10] weeks, with Dr. [Last Name (STitle) 5293] in [2-10] weeks, and with Dr. [Last Name (STitle) ] in 4 weeks. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(2) 5897] Dictated By:[Last Name (NamePattern4) 1718] MEDQUIST36 D: [2161-9-28] 17:53:39 T: [2161-9-28] 22:04:30 Job#: [Job Number 42884] Admission Date: [2161-9-22] Discharge Date: [2161-10-1] Date of Birth: [2087-3-2] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This is a 74-year-old gentleman with a history of diet controlled diabetes and hypercholesterolemia who was admitted to an outside hospital on [2161-9-17] with complaints of weakness and dyspnea on exertion. The patient had stated that he is in his usual state of health, able to walk [1-9] miles a day on a treadmill until he noticed 2-3 weeks prior to admission increasing weakness. The patient denies any symptoms of chest pain, pressure or tightness. The patient was admitted to an outside hospital and ruled out for a myocardial infarction. Echocardiogram showed an ejection fraction of 60 percent. The patient had a positive esophagogastroduodenoscopy and was transferred to [Hospital1 69] for a cardiac catheterization and subsequently coronary artery bypass grafting. PAST MEDICAL HISTORY: Diet controlled diabetes mellitus. Peripheral vascular disease Known abdominal aortic aneurysm status post cerebrovascular accident in [2160-2-9] with residual left arm weakness. Chronic bronchitis. Status post right carotid endarterectomy in [2160-2-9]. Status post transurethral resection of the prostate. Status post excision of skin cancer on left shoulder. ALLERGIES: No known drug allergies. PREOPERATIVE MEDICATIONS: 1. Zestril 10 mg p.o. once daily 2. Plavix 75 mg p.o. once daily 3. Aspirin 81 mg p.o. once daily 4. Hydrochlorothiazide 25 mg p.o. once daily 5. Lipitor 20 mg p.o. once daily 6. Corgard 20 mg p.o. once daily 7. Multivitamin. 8. Colace. 9. Magnesium supplement. PREOPERATIVE LABORATORY DATA: Significant for a creatinine of 1.5. The patient's admission physical examination was otherwise unremarkable. HOSPITAL COURSE: The patient was admitted to [Hospital1 346]. He underwent cardiac catheterization which showed a 60 percent proximal left anterior descending lesion, a 50 percent mid left circumflex lesion and 60 percent osteal RCA lesion. The patient was referred to Dr. [First Name (STitle) ] [Name (STitle) ] for coronary artery bypass grafting. As part of the preoperative workup, a Neurology consultation was obtained to evaluate his risk of stroke. The preoperative neurologic evaluation which included an MRA of the brain and carotid and vertebral arteries which showed a remote right frontoparietal infarct with chronic microvascular infarction involving the periventricular white matter. The MRA of the carotid and vertebral arteries showed mild, diffuse decrease in flow signal involving all of the left sided intracranial vessels including the left internal carotid artery with diffusely diminished flow signal within the left common carotid artery and the left internal carotid artery with irregularity and focal narrowing demonstrated just inferior to the bifurcation in the left common carotid artery. The patient was cleared for being taken to the operating room. The patient was taken to the operating room on [2161-9-23] with Dr. [Last Name (STitle) ] and underwent a coronary artery bypass graft times four with left internal mammary artery to the left anterior descending, saphenous vein graft to RCA, saphenous vein graft to OM3 and a Y-graft saphenous vein graft to LM2. The patient tolerated the procedure well and was transferred to the Intensive Care Unit in stable condition. The patient was weaned and extubated from mechanical ventilation on the first postoperative night. Approximately 20 minutes after extubation, the patient developed difficulty breathing and stridor which subsequently required reintubation. The patient remained intubated on postoperative day one, and on postoperative day two, the patient was weaned and extubated from mechanical ventilation successfully without any evidence of stridor. The patient began diuresis. Post extubation, the patient had some mild confusion which was treated with Haldol and subsequently resolved. On postoperative day number three, the patient developed atrial fibrillation which was controlled with amiodarone. The patient was started on a heparin infusion for anticoagulation. On postoperative day number four, the patient was transferred from Intensive Care Unit to the regular part of the hospital. The patient had been started on Lopressor, Captopril and Lasix. The patient was evaluated by Physical Therapy, and it was determined that the patient would benefit from a stay at [Hospital ] Rehabilitation Facility. The patient's pacing wires were removed without incident, and on postoperative day number eight, the patient was cleared for discharge to rehabilitation. CONDITION ON DISCHARGE: Temperature maximum 98.1. Pulse 65 and sinus rhythm with an episode of atrial fibrillation with heart rate of 90-100. Blood pressure 110/42. Respiratory rate 18. Room air oxygen saturation 97 percent. The patient had a chest x-ray on [2161-9-30] which showed small bilateral pleural effusions, flattened diaphragms, no evidence of congestive heart failure or consolidation. Neurological: The patient is awake, alert and oriented times three. The patient has existing left upper extremity weakness which is unchanged. Cardiovascular: Heart is irregularly irregular with no rub or murmur. Respiratory: Breath sounds are clear anteriorly. Posteriorly, the patient has scattered rhonchi without any sputum production. Gastrointestinal: Positive bowel sounds. Soft, nontender and nondistended. The patient was tolerating a regular diet. Extremities: Warm and well perfused. There is trace edema. Sternal incision is open to air. Steri-Strips are intact. There is no erythema or drainage. The arm is stable. The lower extremity vein harvest site is clean and dry. There is no erythema or drainage. DISCHARGE MEDICATIONS: 1. Percocet 5/325 1-2 tablets p.o. every 4-6 hours p.r.n. 2. Imdur 60 mg p.o. once daily. 3. Zantac 150 mg p.o. once daily. 4. Lopressor 50 mg p.o. b.i.d. 5. Amiodarone 400 mg p.o. once daily. 6. Captopril 25 mg p.o. t.i.d. 7. Lasix 20 mg p.o. once daily. 8. Potassium chloride 20 mEq p.o. once daily. 9. Lipitor 20 mg p.o. once daily. 10. Coumadin. The patient is to have 5 mg on [10-1], [2161]. The patient is to have a PT and INR checked on [2161-10-2], and Coumadin dose is to be adjusted for a goal INR of 2 to 2.5. 11. Aspirin 325 mg p.o. once daily. 12. Albuterol metered dose inhaler two puffs p.o. every 6 hours. 13. Atrovent metered dose inhaler two puffs p.o. every 6 hours. The patient is to be discharged to rehabilitation facility in stable condition. The patient is to follow up with Dr. [Last Name (STitle) ] in [2-10] weeks. He is to follow up with Dr. [Last Name (STitle) 5293] in [2-10] weeks. He is to follow up with Dr. [Last Name (STitle) ] in [3-12] weeks. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(2) 5897] Dictated By:[Last Name (NamePattern4) 8524] MEDQUIST36 D: [2161-10-1] 09:57:36 T: [2161-10-1] 10:42:34 Job#: [Job Number 36262]	[ "414.01", "997.1", "441.4", "401.9", "272.0", "518.5", "250.00", "293.0", "427.31" ]	icd9cm	[ [ [] ] ]	[ "36.15", "37.22", "39.61", "36.13", "96.04", "88.56", "96.71" ]	icd9pcs	[ [ [] ] ]								6257, 6607	12952, 14247					8907, 11786											5113, 5680								6619, 7197	8482, 8889		1423, 2109				6117, 6235																			7226, 8018															8041, 8456	1293, 1390	11811, 12929
56,209	117,730	37711	Discharge summary	report	Admission Date: [2179-9-4] Discharge Date: [2179-9-10] Date of Birth: [2161-6-7] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2534] Chief Complaint: left leg pain Major Surgical or Invasive Procedure: 1. Intramedullary rod fixation of left femur fracture. 2. Irrigation and debridement of left knee traumatic arthrotomy, soft tissue and skin (no bony debridement). 3. Examination under anesthesia of bilateral knees. History of Present Illness: [Known firstname ] [Known lastname 22771] is a 18-year-old gentlemanwho presented to [Hospital1 69] as anactivated trauma following a motor vehicle accident in whichhe was a driver and his car struck a tree. He was evaluated by the trauma team. After their examination diagnosed with agrade 4 liver laceration, several transverse process fractures ,question of a C6 lamina fracture, a left closed femur fractureand after orthopedic evaluation atraumatic arthrotomy to his left knee. Past Medical History: none Social History: Lives with mother, works at Stop and Shop ETOH in excess + Tobacco Family History: non contributory Physical Exam: Temp 98 HR 106 BP 115/56 RR 30 HEENT 3 cm Abrasion on forehead otherwise normal Neck no tenderness C collar in place Chest clear breath sounds bilat COR RRR Abd soft,non tender,abrasion over abd Ext Left thigh hematoma, lac to left femur and left knee Pulses 2+ throughout upper and lower extremities Pertinent Results: [2179-9-4] 06:08AM PT-13.1 PTT-27.3 INR(PT)-1.1 [2179-9-4] 06:08AM PLT COUNT-348 [2179-9-4] 06:08AM WBC-15.7* RBC-4.65 HGB-14.1 HCT-41.4 MCV-89 MCH-30.3 MCHC-34.1 RDW-13.3 [2179-9-4] 06:08AM ASA-NEG ETHANOL-127* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2179-9-4] 04:10PM GLUCOSE-128* UREA N-10 CREAT-0.7 SODIUM-142 POTASSIUM-5.4* CHLORIDE-114* TOTAL CO2-19* ANION GAP-14 [2179-9-4] 09:27PM HCT-29.1* [2179-9-4] Head CT : No acute intracranial process. Specifically, no evidence of acute hemorrhage. Multiple radiopaque tiny foreign bodies in the subcutaneous tissue mostly on the left facial frontoparietal area. [2179-9-4] CT Abd and pelvis and chest : 1. Grade IV/V liver laceration with perihepatic blood tracking along the right pericolic gutter into the pelvis and adjacent to the spleen. 2. Bilateral airspace opacification at the lung bases, concerning for aspiration. 3. Lateral nondisplaced right lower thoracic rib fractures, overlying the liver injury and nondisplaced L2 and L3 transverse process fractures [2179-9-4] CT C spine : No fracture or dislocation. Subtle symmetrical lucency at the lamina, and facets at C6, could be due to motion. [2179-9-4] Left femur : Oblique angulated midshaft left femur fracture. Brief Hospital Course: Mr. [Known lastname 22771] was admitted to the hospital and evaluated by the Trauma Team as well as the Ortho Trauma service. He has a grade IV/V liver laceration on Abd. CT but a stable hematocrit. He remained stable hemodynamically and was taken to the Operating Room by the Orthopedic surgeons and underwent ORIF of left femur and debridement of left knee ( see formal Op note for more details). He received 2 units of prbc's in the OR for acute blood loss. He was transferred to the ICU for further management. His hematocrit remained stable and his abdomen was soft. He was extubated the following day and his pain was controlled with a Dilaudid PCA. He remained in the ICU for close monitoring of his Hct and abdominal exam due to the liver laceration. From an orthopedic standpoint he was doing well. He received 3 units of blood on [2179-9-6] for a hct of 22 as he was dizzy when getting out of bed and also tachycardic at 100. This was attributed to anemia in the setting of acute blood loss. Following traansfer to the surgical floor he continued to make good progress. His hematocrit was stable in the 25 range, he was tolerating a regular diet and he was working with Physical Therapy to progress on his ambulation. He was started on Lovenox after it was demonstrated that his hematocrit was stable and he was instructed how to administer this by the nursing staff. He was discharged home on [2179-9-10] and will follow up with Dr.[Name (NI) 68773] and Dr. [Last Name (STitle) ]. Medications on Admission: none Discharge Medications: 1. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day for 1 months. 5. Outpatient Physical Therapy Motor vehicle crash with ORIF Left femur Evaluation and treatment 6. Enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg Subcutaneous DAILY (Daily) for 4 weeks. Disp:30 syringes Refills:0 Discharge Disposition: Home Discharge Diagnosis: 1. Left femur fracture. 2. Left knee traumatic arthrotomy. Discharge Condition: stable Discharge Instructions: DO NOT PARTICIPATE IN ANY CONTACT SPORTS OR ANYTHING THAT WOULD CAUSE PRESSURE OR TRAUMA TO YOUR ABDOMEN RETURN TO THE EMERGENCY ROOM IMMEDIATELY IF YOU HAVE ANY DIZZINESS OR LIGHTHEADEDNESS AS THIS COULD BE A SIGN THAT YOU ARE BLEEDING. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [4-25] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. Followup Instructions: Follow up with Dr. [Last Name (STitle) ] in 2 weeks [Telephone/Fax (1) 1228] Staples will be removed at that time. Call Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 2359] for a follow up appointment in 2 weeks. Completed by:[2179-9-14*]	[ "891.1", "864.01", "790.01", "998.11", "305.00", "E878.1", "864.05", "865.01", "821.01", "805.4", "E812.0" ]	icd9cm	[ [ [] ] ]	[ "83.39", "99.04", "79.35", "38.91" ]	icd9pcs	[ [ [] ] ]	5130, 5136	2878, 4403	326, 548	5239, 5248	1556, 2855	7380, 7643	1202, 1220		4458, 5107		5157, 5218		4429, 4435			5272, 6969							6985, 7357		1235, 1537																								273, 288										576, 1074															1096, 1102	1118, 1186
27,115	122,178	33947	Discharge summary	report	Admission Date: [2173-6-8] Discharge Date: [2173-6-23] Date of Birth: [2152-1-25] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4691] Chief Complaint: s/p Assault Major Surgical or Invasive Procedure: [2173-6-14] Tracheostomy, IVC filter and PEG tube placement [2173-6-21] Tracheostomy decannulation History of Present Illness: 21 y/o male s/p assault, was reportedly kicked multiple times to head; +LOC. He was transported to [Hospital1 18] for furhter care. Upon arrival to [Hospital1 18] his GCS~[7-6] and he was intubated and sedated to protect his airway. Past Medical History: Unknown Family History: Noncontributory Physical Exam: Upon admission: 96.3 86 126/61 22 100% on CMV @100% 677x22 PEEP=5 Gen: intubated,sedated HEENT: Pupils 3 to 2 mm, PERRLA Neck: Supple. (-)cervical LAD, (-) JVD Lungs: CTA B/L Cardiac: RRR. Abd: Soft, NT, BS+ Extrem: warm and well-perfused,No C/C/E Neuro: DOES NOT RESPOND TO COMMANDS,LOCALIZES TO PAIN Mental status:sedated,intubated Orientation: UNABLE TO ASSESS Recall: UNABLE TO ASSESS Language: UNABLE TO ASSESS Naming intact UNABLE TO ASSESS Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: UNABLE TO ASSESS V, VII: UNABLE TO ASSESS VIII: UNABLE TO ASSESS IX, X: UNABLE TO ASSESS [Doctor First Name 81]: UNABLE TO ASSESS XII: UNABLE TO ASSESS Motor: Normal bulk and tone bilaterally. MOVES ALL 4 LIMBS UNABLE TO ASSESS pronator drift Sensation: UNABLE TO ASSESS Reflexes: B T Br Pa Ac Right 1+------------- Left 1+------------ Toes downgoing bilaterally Coordination: UNABLE TO ASSESS Pertinent Results: CT/MRI: [2173-6-8] NC Head CT: 1. Small left convexity subdural hematoma, and multiple foci of left frontotemporal traumatic subarachnoid hemorrhage, with local edema and mass effect on the left lateral ventricle, and 4-mm rightward subfalcine herniation. 2. Right occipital bone fracture, with extension into the right occipital condyle. Non-displaced left occipital condyle fracture. Moderate right occipital subgaleal hematoma. 3. Comminuted nasal bone fractures. [Known lastname 78423],[Known firstname ] [Medical Record Number 78424] M [2092-1-18] Radiology Report CT C-SPINE W/O CONTRAST Study Date of [2173-6-8] 1:23 AM CT C-SPINE W/O CONTRAST Clip # [Clip Number (Radiology) 78425] FINDINGS: There is no cervical spine fracture or malalignment. Known right occipital bone fracture, and bilateral occipital condyle fractures are better evaluated and described in detail on concurrently performed head CT. There is mild straightening of normal cervical lordosis which may be due to positioning and cervical collar. Endotracheal tube is in place, with some inspissated secretions in the pharynx. Small amount of air is noted posterior and adjacent to the left clavicle, prevertebral and paraspinal soft tissues are otherwise unremarkable. Visualized outline of the thecal sac appears normal, but please note that CT is unable to provide intrathecal detail comparable to MRI. IMPRESSION: No cervical spine fracture or malalignment. Radiology Report CHEST (PORTABLE AP) Study Date of [2173-6-16] 9:30 AM HISTORY: Tracheostomy. Very frequent cough. Evaluate tube tip. IMPRESSION: AP chest compared to [6-14]: Tracheostomy tube is midline. Consolidation at the right lung base has improved since [6-14]. Heart size is top normal. Pleural effusion, if any, is minimal. No pneumothorax. [2173-6-8] 09:09AM GLUCOSE-128* UREA N-16 CREAT-1.1 SODIUM-139 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-27 ANION GAP-15 [2173-6-8] 09:09AM PHENYTOIN-7.5* [2173-6-8] 09:09AM WBC-14.9* RBC-5.25 HGB-15.5 HCT-45.6 MCV-87 MCH-29.6 MCHC-34.1 RDW-13.2 [2173-6-8] 09:09AM PLT COUNT-242 [2173-6-8] 01:15AM ASA-NEG ETHANOL-129* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2173-6-8] 01:15AM WBC-11.7* RBC-5.47 HGB-17.0 HCT-46.4 MCV-85 MCH-31.1 MCHC-36.8* RDW-12.6 [2173-6-8] 01:15AM PLT COUNT-310 [2173-6-8] 01:15AM PT-11.4 PTT-20.3* INR(PT)-0.9 Brief Hospital Course: He was admitted to the Trauma service. Neurosurgery was consulted urgently due to the brain injury. He was loaded with Dilantin 1 g and started on 100 mg TID and was also given 100 g Mannitol at bedside. Serial head CT scans were followed and were stable. A port ion of his skull was removed and will be replaced at a later date by Neurosurgery. He was fitted with a helmet and this will need to be worn at all times. He remained in the Trauma ICU for over a week intubated and sedated. A tracheostomy, PEG and IVC filter were placed on [6-14]. Tube feedings were initiated. His sedation was weaned and he was very restless requiring Ativan and Haldol. He was able to be weaned from the ventilator. The Ativan was eventually stopped and he was started on standing Haldol. There has been marked improvement in his mental status. His tracheostomy was removed on [6-21] and a bedside evaluation was done; his diet was advanced and he is tolerating this without any difficulties. Social work has been closely involved with patient and his family throughout his hospital stay provided emotional support. Physical and Occupational therapy were consulted and have recommended [Hospital ] rehab after acute hospital stay. Medications on Admission: Unknown Discharge Medications: 1. Haloperidol 2 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 2. Haloperidol 2 mg Tablet Sig: One (1) Tablet PO every [4-4] hours as needed for agitation. 3. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain. 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: hold for loose stools. 8. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for constipation. 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML's Injection [Hospital1 ] (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: s/p Assault Traumatic Brain Injury Cranial fracture Left subdural hematoma Left frontal subarachnoid hemorrhage Respiratory failure Discharge Condition: Good Followup Instructions: Follow up with Dr. [Last Name (STitle) ], Neurosurgery in [6-6] weeks, call [Telephone/Fax (1) 1669] for an appointment. Inform the office that a repeat head CT scan will be needed for this appointment. Also please confirm with the office that surgery has been scheduled for replacing the portion of your skull. Follow up with Dr. [Last Name (STitle) ], Trauma Surgery for removal of the gastrostomy feeding tube in the next 1-2 weeks. Call [Telephone/Fax (1) 6429] for an appointment when appropriate. Completed by:[2173-6-28]	[ "E960.0", "518.81", "348.5", "482.40", "801.25", "802.0", "482.83", "999.9", "348.4" ]	icd9cm	[ [ [] ] ]	[ "96.6", "96.04", "01.10", "38.7", "31.1", "43.11", "38.93", "96.72", "97.37", "01.25" ]	icd9pcs	[ [ [] ] ]	6507, 6577	4279, 5511	325, 434	6753, 6760	1812, 1838	6783, 7338	756, 773		5569, 6484		6598, 6732		5537, 5546												788, 790																								274, 287										462, 709	1254, 1793				1847, 4256				804, 1093		1107, 1238				731, 740
78,739	149,179	39382	Discharge summary	report	Admission Date: [2120-2-21] Discharge Date: [2120-2-26] Date of Birth: [2061-2-4] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / adhesive tape / Codeine / Nsaids / Percocet / Morphine / Alcohol / Band-Aid Clear Spots / Latex / Aspirin / Valium / Sulfamethoxazole / Betadine Skin Cleanser / Diphenhydramine Attending:[First Name3 (LF) 5790] Chief Complaint: dyspnea with ADL's Major Surgical or Invasive Procedure: [2120-2-21]: Right thoracotomy and thoracic tracheoplasty with mesh, right mainstem bronchus/bronchus intermedius bronchoplasty with mesh, left mainstem bronchus bronchoplasty with mesh, bronchoscopy with bronchoalveolar lavage. History of Present Illness: The patient is a 59-year-old woman who has had dyspnea and cough and was found to have severe diffuse tracheobronchomalacia more prominent in the distal trachea and bilateral bronchi. She underwent a stent trial and reported dramatic interval relief and functional improvement. The patient was consented for a tracheobronchoplasty and understood that the long-term performance of the operation was not clear, that there were risks of incomplete symptom alleviation, new symptoms creation, or recurrent symptomatology. Past Medical History: COPD Oropharyngeal candidiasis OSA on CPAP GERD Insomnia Fibromyalgia Carrier of Z alpha-1 antitrypsin gene SVT s/p ablation [2109] Cholecystectomy [2113] Social History: Lives with her boyfriend in [Name (NI) 1727]. Limited transportation to [Location (un) 86]. Occupation: unemployed Smoking history: 35 pck/y, quit 10 years ago. Alcohol: denies Family History: Mother- Alive at 79 with breast cancer s/p mastectomy and pulmonary problems, DM, CHF Father [Name (NI) 87058] with breast cancer, sister with thyroid cancer Offspring Other Physical Exam: Discharge Vital signs: T 97.8, HR 95, BP 118/66, RR 20, O2 sats 94% 2L resting, 91-95% 4L with ambulation. Pain controlled. Discharge exam: Gen: pleasant in NAD, A & O x 3 without deficits Lungs: course b/l with clearing with cough. Right thoracotomy incision with erythmema and slight swelling, which is stable from postop. CV: RRR S1, S2, no MRG or JVD Abd: soft, NT, ND Ext: warm without edema Pertinent Results: [2120-2-26] 06:35AM BLOOD WBC-8.8 RBC-3.49* Hgb-11.6* Hct-34.1* MCV-98 MCH-33.2* MCHC-33.9 RDW-13.9 Plt Ct-255 [2120-2-26] 06:35AM BLOOD Glucose-107* UreaN-11 Creat-0.8 Na-138 K-3.9 Cl-98 HCO3-30 AnGap-14 [2120-2-26] 06:35AM BLOOD CK(CPK)-1076* [2120-2-24] 06:30AM BLOOD CK(CPK)-6187* [2120-2-23] 01:18PM BLOOD CK(CPK)-9463* [2120-2-23] 01:53AM BLOOD CK(CPK)-[Numeric Identifier 87059]* [2120-2-22] 02:11PM BLOOD CK(CPK)-[Numeric Identifier 87060]* [2120-2-22] 08:45AM BLOOD CK(CPK)-[Numeric Identifier 13911]* [2120-2-22] 01:29AM BLOOD CK(CPK)-[Numeric Identifier 43519]* [2120-2-21] 05:41PM BLOOD CK(CPK)-4365* [2120-2-26] 06:35AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.0 CXR [2120-2-24]: FINDINGS: Two views of the chest compared to prior study from [2120-2-23] demonstrate a small-to-moderate right-sided pleural effusion, small left-sided pleural effusion, bibasilar atelectasis, little changed from prior study. Moderate interstitial prominence throughout right lung, little changed since prior study. Brief Hospital Course: Ms. [Known lastname 31] is a 59 year old female with tracheobronchomalacia, from [State 1727] who underwent tracheobronchoplasty by Dr. [Last Name (STitle) ] on [2120-2-21]. She transferred to the ICU postoperatively for airway observation, and was kept until [2120-2-23], at which time she transferred to the floor on telemetry. The following is her hospital course: Neuro/Pain: The patient had a bupivicaine epidural initially which was dc'd [2-23] and pain controlled with PCA dilaudid, then po dilaudid and tylenol, which was effective. She remained neurologically intact. Pulmonary: Aggresive pulmonary toilet continued with Albuterol and mucomyst nebs. She was weaned to 2L nasal cannula oxygen at rest and 4L with ambulation. She used CPAP at night for known OSA. She had a right chest tube which dc'd [2-23] without pneumothorax on post pull film. She was diuresed x 3 days with lasix 10mg po daily for pulmonary edema and small right effusion on chest xray, which improved. Cardiovascular: She remained hemodynamically stable throughout her course. Nutrition: She was started on sips [2120-2-22] which was advanced to a regular diet and tolerated without dysphagia. She was continued on PPI. Renal: She had a foley from the operating room, which was dc'd [2120-2-23] with good urine thereafter. She was started on a bicarb gtt [2120-2-23] for rhabdo with CK max of 19,123 on [2-22] and down to 1076 on date of discharge. Her chemistry panel was watched daily and on date of discharge her creatinine was 0.8, with highest 1.2 date of surgery. Electrolytes were replaced as needed. Infectious Disease: The patient's CBC and fever curves were monitored. She spiked to 102.2 on [2120-2-22] and had blood and urine cultures, which thus far were negative, without temperatures since [2120-2-23]. Vancomycin x2 post-op completed. She had a right erythematous incision which was stable and not felt to require any antibiotics. Dispo: PT evaluated the patient and cleared her for home without home PT. The patient was ambulating well with controlled pain, tolerating a regular diet, with ambulatory sats 4L NC of 91-95%. She was deemed stable for home discharge [2120-2-26] by Dr. [Last Name (STitle) ]. She was initially going to leave with a service car but they could not take her oxygen tanks therefore she stayed another couple of hours until ambulance transport was arranged to take her with oxygen up to [State 1727]. [Hospital1 5065] home oxygen was arranged and were going to deliver a portable tank once she arrived home. The patient was given scripts for nebulizers, and will see us in clinic in two weeks. Discharge Medications: 1. home oxygen 4L NC continuous pulse dose for portability. Dx Tracheobronchomalacia with O2 sats <88% on Room air. 2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device [Hospital1 ]: One (1) Cap Inhalation DAILY (Daily). 3. cyclosporine 0.05 % Dropperette [Hospital1 ]: One (1) Dropperette Ophthalmic [Hospital1 ] (2 times a day). 4. venlafaxine 25 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day. 5. docusate sodium 100 mg Capsule [Hospital1 ]: One (1) Capsule PO BID (2 times a day) as needed for prn constipation. 6. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 7. hydromorphone 2 mg Tablet [Last Name (STitle) ]: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 8. Mucinex 1,200 mg Tablet, ER Multiphase 12 hr [Last Name (STitle) ]: One (1) Tablet, ER Multiphase 12 hr PO twice a day as needed for thick secretions. 9. nitrofurantoin macrocrystal 50 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO at bedtime: per your PCP. 10. polyethylene glycol 3350 Powder [Last Name (STitle) ]: One (1) capful Miscellaneous once a day. 11. Metamucil 3.3 gram/5.95 gram Powder [Last Name (STitle) ]: One (1) dose PO once a day as needed for constipation: or as you were previously taking. 12. Caltrate 600+D Plus Minerals 600 mg (1,500 mg)-400 unit Tablet, Chewable [Last Name (STitle) ]: One (1) Tablet, Chewable PO once a day. 13. VIACTIV Multi-Vitamin 200-0.4 mg Tablet, Chewable [Last Name (STitle) ]: One (1) Tablet, Chewable PO once a day: as you were taking prior to admission. 14. Vitamin C 500 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO four times a day. 15. Nasacort AQ 55 mcg Aerosol, Spray [Last Name (STitle) ]: One (1) squirt Nasal twice a day: or as you were taking, instructed by PCP. 16. Alvesco 80 mcg/Actuation HFA Aerosol Inhaler [Last Name (STitle) ]: One (1) puff Inhalation twice a day. 17. zolpidem 10 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO at bedtime. 18. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device [Last Name (STitle) ]: One (1) puff inh Inhalation once a day. 19. omega-3 fatty acids 1,000 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO twice a day. 20. fluorometholone 0.1 % Drops, Suspension [Last Name (STitle) ]: One (1) drop Ophthalmic once a day: to both eyes. 21. vitamin E 400 unit Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 22. Pataday 0.2 % Drops [Last Name (STitle) ]: One (1) drop Ophthalmic once a day: continue as you were prior to surgery. 23. fluorometholone 0.1 % Drops, Suspension [Last Name (STitle) ]: One (1) drop to eyes Ophthalmic once a day. 24. acetylcysteine 20 % (200 mg/mL) Solution [Last Name (STitle) ]: Three (3) ml Miscellaneous every twelve (12) hours: take for thick secretions. Disp:200 ml Refills:2 25. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Last Name (STitle) ]: One (1) neb Inhalation three times a day as needed for shortness of breath or wheezing: give with mucomyst. Disp:90 nebs Refills:2 26. Tylenol Extra Strength 500 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO every eight (8) hours. Discharge Disposition: Home With Service Facility: [Doctor First Name 87061] Homecare and Hospice Discharge Diagnosis: Tracheobronchomalacia COPD OSA on CPAP GERD Insomnia Fibromyalgia Carrier of Z alpha-1 antitrypsin gene Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr. [Last Name (STitle) ] [Telephone/Fax (1) 2348] if you have fevers greater than 101.5, worsening productive cough, or worsening shortness of breath. Call if your incision develops drainage or worsening swelling or drainage. Walk several times a day, and continue to use the incentive spirometer. Home oxygen: 4L NC to keep oxygen saturations greater than 92% Nebulizers: Use mucomyst and albuterol twice a day, along with mucinex to help with thick secretions. Drink fluids with this. Followup Instructions: Provider: [Name10 (NameIs) 1532] [Last Name (NamePattern4) 8786], MD Phone:[Telephone/Fax (1) 3020] Date/Time:[2120-3-12] 11:00, WPC [Hospital1 ] 116 Get a chest xray on [Location (un) 470] radiology clinical center 30 minutes prior to your discharge. Followup with your PCP [Name Initial (PRE) 7274]: [Name10 (NameIs) 87062],[Name11 (NameIs) ] [Name Initial (NameIs) ] Location: [Hospital ] MEDICAL CENTER Address: UNIT [Unit Number ], FIVE MILES CENTER, DAMARISCOTTA,[Numeric Identifier 87063] Phone: [Telephone/Fax (1) 87064] Fax: [Telephone/Fax (1) 87065] in [12-3] weeks for postoperative check. Call office for appt. We have left a message with them that you need a followup. Completed by:[2120-2-26]	[ "780.62", "327.23", "519.19", "786.09", "273.4", "729.1", "530.81", "780.52", "309.81", "496" ]	icd9cm	[ [ [] ] ]	[ "31.79", "03.90", "33.48", "33.24" ]	icd9pcs	[ [ [] ] ]	9417, 9498	3375, 3746	475, 710	9646, 9646	2279, 3352	10326, 11104	1665, 1845		6097, 9394		9519, 9625			3764, 6074		9797, 10303									1860, 1985						2001, 2260																		417, 437										738, 1259											9661, 9773				1281, 1446	1462, 1649
1,212	178,788	21072	Discharge summary	report	Admission Date: [2183-10-14] Discharge Date: [2183-11-4] Date of Birth: [2134-10-2] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1556] Chief Complaint: Status post motorcycle accident. Major Surgical or Invasive Procedure: Exploratory laparotomy with splenectomy. Open reduction internal fixation of right anterior/posterior pelvic rings. Open reduction internal fixation of left anterior column fracture. Open reduction internal fixation left tibial plateau fracture. Placement of IVC filter. Past Medical History: Hypertension, hyperlipidemia, Diabetes Mellitus (type 2), s/p ORIF right Tib-fib. Family History: Noncontributory. Physical Exam: On arrival: GEN- intubated, sedated PULM: equal breath sounds bilaterally, adequate/equal chest wall excursion, good color change EXT: skin mottled Pertinent Results: [2183-10-14] 12:15AM ASA-NEG ETHANOL-156* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG --- TECHNIQUE: Cervical spine CT, with sagittal and coronal reformatting without intravenous contrast. IMPRESSION: 1. No evidence of traumatic injury. 2. Likely prominent, but normal epidural venous plexus. If there is a persistent concern, then a contrast-enhanced CT can be helpful to confirm this supposition. ---- CT L-SPINE W/O CONTRAST Clip # [Clip Number (Radiology) 55949] IMPRESSION: Comminuted fracture of the right sacral ala. Small osseous fragments along the inferior aspect of the left L3/4 facet joint complex, likely fracture fragments of indeterminate age. ----- CT T-SPINE W/O CONTRAST Clip # [Clip Number (Radiology) 55950] IMPRESSION: No evidence of traumatic injury of the thoracic spine. Right lower lobe consolidation, which may represent atelectasis or aspiration. Clinical correlation recommended. ------ CT PELVIS ORTHO W/O C Clip # [Clip Number (Radiology) 55951] IMPRESSION: 1. Complex left acetabular fracture. The more comminuted complex fracture involves the anterior acetabulum with a small minimally displaced posterolateral acetabular component of the fracture. 2. Right sacral fracture. No SI joint widening. 3. Right pubic symphysis/inferior ramus and left inferior pubic ramus fractures. No widening at the pubic symphysis. 4. Laterally displaced left greater trochanteric fracture. 5. Minimal impaction fracture at the anterior left femoral head. 6. Retroperitoneal/presacral fluid/blood. The patient is status post a recent laparotomy. ------------------- Brief Hospital Course: Mr. [Known lastname 55952] was transferred to [Hospital1 18] from [Hospital3 ] with unstable vital signs and hemorrhagic shock refractory to resuscitation. He was emergently taken to the OR for exploratory laparotomy and splenectomy secondary to CT findings of a ruptured spleen. Postoperatively, he was transferred to the TSICU. He returned to the OR on [2183-10-17] for placement of an IVC filter and ORIF of his pelvic fractures, and his left tibial plateau. He tolerated the procedures well and continued to progress in the TSICU. He did have some difficulty with slowly improving mental status and a repeat head CT was obtained on hospital day 5 which did not reveal any new changes. On hospital day 8, the patient was placed on precidex, weaned, and extubated successfully. He was transferred to the floor on hospital day 10, where he continued to improve. He was administered the meningococcal, pneumovax, and haemophilus influenza vaccinations prior to discharge as asplenic prophylaxis. On hospital day 21, the patient was cleared by physical therapy for discharge to home with services. Medications on Admission: Amlodipine, allopurinol, lisinopril, glypizide Discharge Medications: 1. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Acetaminophen 160 mg/5 mL Solution Sig: [12-9] PO Q4-6H (every 4 to 6 hours) as needed. 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Docusate Sodium 150 mg/15 mL Liquid Sig: Two (2) tsp PO TID (3 times a day). 9. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 10. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 12. Felodipine 5 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). 13. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for thick secretions. 14. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 15. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed for insomnia. 16. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 17. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 18. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 19. Methadone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 20. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for breakthrough pain. Discharge Disposition: Home With Service Facility: [Location (un) ] Nursing Association Discharge Diagnosis: 1. Status-post MVC. 2. Status-post splenectomy. 3. Status-post IVC filter placement. 4. Status-post ORIF right anterior pelvic ring, right posterior pelvic ring, anterior column acetabular fracture, and left tibial plateau fracture. Discharge Condition: Good. Discharge Instructions: Call your doctor or return to the emergency department if you experience any of the following: worsening pain, inability to eat or drink, chest pain, shortness of breath, redness, pain, or swelling at your incision sites, any new or concerning symptoms. Please take all of your prescribed medications. Followup Instructions: Please follow-up in the [Hospital 5498] clinic with Dr. [Last Name (STitle) 1005] in two weeks. You will need to call [Telephone/Fax (1) 1228] for an appointment. You will also need to follow up in the trauma clinic in two weeks. Call [Telephone/Fax (1) 6429] for an appointment.	[ "250.00", "401.9", "808.0", "305.1", "861.21", "305.00", "E816.2", "865.04", "958.4", "518.5", "272.4", "808.49", "286.9", "805.6", "823.00" ]	icd9cm	[ [ [] ] ]	[ "38.7", "41.5", "99.06", "38.93", "79.36", "79.39", "38.91", "99.05", "99.07", "96.72", "33.24", "96.6", "99.04", "03.53" ]	icd9pcs	[ [ [] ] ]	5587, 5658	2607, 3722	348, 620	5935, 5943	945, 2584	6294, 6594	742, 760		3819, 5564		5679, 5914		3748, 3796			5967, 6271									775, 926																								276, 310																									642, 726
3,977	133,203	54130	Discharge summary	report	Admission Date: [2148-10-1] Discharge Date: [2148-10-2] Date of Birth: [2098-10-13] Sex: F Service: MEDICINE Allergies: Demerol / Compazine / Reglan / Betadine Surgi-Prep / Tape [11-26]"X10YD / Iodine-Iodine Containing / Vancomycin Attending:[First Name3 (LF) 99] Chief Complaint: abdominal pain and rigors Major Surgical or Invasive Procedure: none History of Present Illness: 49F w/ [Location (un) ] Syndrome and an extensive surgical history including total colectomy and end ileostomy on chronic TPN now w increasing abdominal pain, nausea, and bilious vomiting x 1 day. Also complains of subjective fevers and chills, and says that this episode is similar to prior episodes of bacteremia due to line infections. Denies chest pain and shortness of breath. On tpn at home, and by report, apparently her dog has been biting the catheter tip yet she has continued to use PICC, concerned for line infection. She was brought by her PCA to [Hospital 16843] Hospital, where vitals were 98.3 127 96/45 20 and she complained of diffuse abdominal pain. WBC count 7.4 w/ 96% neutrophils, Hct 32.9, Plt 122, ALT 67, AST 42. She got 2L IV fluids, Zofran and Dilaudid, but remained tachycardic. By her request she was transferred to [Hospital1 18]. In the ED, initial vitals were 98.2 116 102/58 18 94%. BP in 90s, dropping to the 80s despite 4L IVF. Having rigors, appears unwell. Started on Zosyn and Daptomycin. Has PICC in L femoral, claims to have clotted off all the rest of her veins. Ended up getting non-con CT as radiology will not use Hickman and patient allergic to iodine. No PIVs. Vitals prior to transfer 97.7 99/51 124 92%RA. On the floor, patient complaining of ongoing nausea and severe bilateral lower-quadrant, sharp, unremitting abdominal pain. Per patient's sister, the patient DNR/DNI, which was confirmed with the patient. The patient is alright with getting pressors and continuing antibiotics, but did not want an arterial line. Past Medical History: ++ [Location (un) ] syndrome - diagnosed age 23 - total colectomy, end ileostomy [2121] - small bowel resection (multiple) secondary to recurrent polyposis - subsequent short gut syndrome - on TPN since [2123], [9-/2131] ++ Benign cystadenoma - partial hepatectomy, [2131] ++ Line-associated blood stream infections - Her CVL in her L leg has been in place for at least 5 years, when she has had infections the line has been changed over a wire as pt has limited remaining access (L groin vessels and hepatic vessels are only usable vessels) - MSSA, [2127] - [First Name5 (NamePattern1) 564] [Last Name (NamePattern1) 563] [12/2139] - C. parapsilosis + coag neg Staph, [2-/2140] - [Female First Name (un) 564] non-albicans, [3-/2141] - C.parapsilosis, [9-/2142] - K. pneumoniae, [9-/2145] --> Resistant to cipro, cefuroxime, TMP/SMX --> Treated with meropenem [Date range (1) 110935]/08 - Line change due to positive blood cultures (?) [10/2145] --> Had an echocardiogram that was abnormal as noted below Coag neg Staph [1-/2146] --> Line changed over wire --> Linezolid [Date range (1) 110936] --> Coag Neg Staph [6-1], no line change, on Dapto till [2146-6-28] - Admitted to [Hospital1 18] [2145-9-27] with history of + urine for VRE isolated on [2145-9-8] at Healthcare [Hospital 4470] hospital. ++ Venous thrombosis/occlusion - Failed access in R IJ, R brachiocephalic - Reconstructed IVC w/ kissing stent extensions into high IVC - Stenting to R femoral, external iliac ++ GI bleed ++ HSV-1 ++ Fibromyalgia ++ Osteoporosis ++ Scoliosis; h/o surgical repair ++ Right hip fracture; ORIF [2129] ++ Meniscal tears of knee; 4 prior surgeries, [2133] ++ Total abdominal hysterectomy; bilateral salpingo-oophorectomy ++ Left multiple metatarsal fractures [11/2146] ++ Dermoid cyst removal (small bowel, ovaries) ++ Hepatic cyst adenoma; resected ++ Cholecystectomy, [2131] ++ ? Paradoxical emboli ++ Intracranial Hemmorhage on fondaparinux [10/2146] ++ Chronic left eye blindness and expressive aphasia ++ Multiple PE and DVT, most recent in [11/2145] Social History: Lives with her elderly mother. She is cared for by PCA's and a private nurse. - Tobacco: none - Alcohol: none - Illicits: none Family History: Father and 6 of 8 siblings with [Location (un) ] syndrome. Mother and relatives with HTN and resulting CVA. Sister with breast cancer. Her father's parents died of cancer. Physical Exam: ADMISSION EXAM: General: Drowsy but easily arousable, moderate respiratory distress HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Tachypneic, decreased breath sounds at right base, clear otherwise CV: Tachycardic and hyperdynamic, no murmurs Abdomen: patient sitting with knees up to chest, abdomen soft, diffusely tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: PICC line in place with slight surrounding erythema. Extremities warm with 2+ pulses. Neuro: aaox3, CNs [1-6] intact, moving all extremities. Pertinent Results: ADMISSION LABS: [2148-9-30] 10:40PM BLOOD WBC-13.6# RBC-3.83 Hgb-11.2# Hct-35.0# MCV-91# MCH-29.3# MCHC-32.1 RDW-13.8 Plt Ct-181 [2148-9-30] 10:40PM BLOOD Neuts-92.8* Lymphs-5.2* Monos-1.6* Eos-0.3 Baso-0.1 [2148-10-1] 05:00AM BLOOD PT-21.3* PTT-46.2* INR(PT)-2.0* [2148-9-30] 10:40PM BLOOD Glucose-102* UreaN-19 Creat-0.9 Na-139 K-4.1 Cl-110* HCO3-18* AnGap-15 [2148-9-30] 10:40PM BLOOD ALT-48* AST-42* AlkPhos-251* TotBili-0.9 [2148-9-30] 10:40PM BLOOD Albumin-3.3* [2148-10-1] 06:04AM BLOOD Type-ART Temp-36.6 FiO2-60 O2 Flow-10 pO2-90 pCO2-37 pH-7.22* calTCO2-16* Base XS--11 Intubat-NOT INTUBA Comment-SIMPLE FAC [2148-10-1] 11:38AM BLOOD Lactate-5.9* URINE: [2148-10-1] 01:30AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.016 [2148-10-1] 01:30AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM [2148-10-1] 01:30AM URINE RBC-1 WBC-8* Bacteri-FEW Yeast-NONE Epi-1 TransE-<1 MICRO: [2148-10-1] BCx: KLEBSIELLA OXYTOCA \| AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S STUDIES: [2148-10-1] CXR: No acute cardiac or pulmonary process. No change from prior radiographs from [2147-1-31]. [2148-10-1] CT abd: 1. Right lower lobe consolidation is concerning for infection. 2. No acute intra-abdominal or pelvic process. 3. Diffusely hypodense liver, most consistent with focal fat deposition. Brief Hospital Course: Ms. [Known lastname 1557] is a 49 year old woman with h/[Initials (NamePattern4) ] [Last Name (NamePattern4) ] syndrome, short gut syndrome, prior line infections, only access is L femoral Hickman, who was admitted with abdominal pain and rigors, found to have GNR bacteremia. The patient was septic on admission, requiring BP support with 3 pressors. She was treated with Meropenem. The patient was tachypneic and satting in the 70-90s on NRB. Given her pain and increased work of breathing, patient was started on a morphine gtt. She was made comfort measures only on [2148-10-2], and passed away later the same day. Medications on Admission: - fentanyl 200mcg/72hrs - famotidine 40mg IV daily - amitriptyline 50mg QHS - Benadryl 50mg Q12hrs - Ativan 1mg PO Q4-6hrs PRN - morphine oral solution 2-4mg Q6hrs PRN - Zofran 8mg IV Q8hrs PRN - warfarin 4mg Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: GNR bacteremia Discharge Condition: Expired. Discharge Instructions: None. Followup Instructions: None.	[ "276.2", "729.1", "579.3", "733.00", "V45.72", "995.92", "038.40", "999.32", "785.52", "V44.2" ]	icd9cm	[ [ [] ] ]	[ "99.15" ]	icd9pcs	[ [ [] ] ]	7930, 7939	7004, 7640	401, 407	7997, 8007	5230, 5230	8061, 8069	4372, 4549		7900, 7907		7960, 7976		7666, 7877			8031, 8038									4564, 5211																								336, 363										435, 2018							5246, 6981								2040, 4212	4228, 4356
21,753	197,128	46553	Discharge summary	report	Admission Date: [2127-2-25] Discharge Date: [2127-3-5] Date of Birth: [2054-9-13] Sex: F Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 759] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Colonoscopy Upper Endoscopy History of Present Illness: 72 yo F w/ h/o AAA, lung ca s/p lobectomy, brain ca s/p resection, A fib, and esophageal strictures s/p multiple dilations who presents as transfer from OSH for evaluation of GI bleeding and AAA. Patient presented to OSH c/o burning, intermittent epigastric abdominal pain x 2 days. She reports feeling unwell x 5 weeks. C/o "upset stomach," dizziness, and nausea x 5 weeks. Also reports falls x 3 over last few weeks. Last fall end of last week due to dizziness, denies LOC or head trauma. Reports one episode BRBPR at home yesterday, but denies melena. Also reports "spitting up blood," over last few days (small amounts). +weight loss over last few weeks, but unsure of amount. Also reports occasional blood transfusions and iron infusions given by PCP over last several months (2 units in last 6 weeks). Never had C-scope in past. Currently taking ASA 81mg daily, denies any NSAID use, denies coumadin use. Last on coumadin 8-9yrs ago. . On presentation to OSH, patient found to be hypotensive w/ BP 76/52, HR 94. Hct 24.6, PTT 87.7 sec, PT >120 sec, INR >9.58. CT abdomen revealed 5.11cm AAA, which was increased from size of 4.1 by U/S approx 1 month ago. CT did not show evidence of RP bleed. Given Vitamin K 10mg x1 and 2 units PRBCs. NGL reportedly negative at OSH. Patient transferred by [Location (un) ] to [Hospital1 18] ED for further management. On arrival to [Hospital1 18], VSS. INR was 6.0, Hct 33.1. Patient had Guaiac + black stool on exam. She was given 2u FFP and Protonix 40mg IV x1. Vascular surgery eval'd pt in ED, who recommend continuing management of GIB. Vascular will follow. . On admission to MICU, patient remained normotensive Past Medical History: lung ca s/p L pneumonectomy [9-/2120] -right parietal lobe enhancing mass s/p resection [2120-4-8]. She then received concurrent chemo-irradiation (names of drugs unknown to her) from [2120-6-10] to [2120-8-9],On repeat MRI of the head, the original surgical site continued to have linear enhancement. She then received stereotactic radiosurgery on [2121-5-28] to 1,500 cGy. - A fib -esophageal stricture s/p multiple dilations -MVP -Known AAA (4.1cm by U/S 1 month ago) Social History: Lives w/ son. +h/o Smoking, quit [2121]. Denies EtOH or drug use. No h/o IVDU, no tatoos. Family History: No family h/o bleeding disorders Physical Exam: VS: T: 97.3; HR: 95; BP: 143/77; RR 12; O2 97% 2LNC GEN: pale, cachectic elderly woman, lying in bed, NAD HEENT: +temporal wasting, PERRL bilat, EOMI bilat, anicteric, MMM, OP clear NECK: JVP at mandible, no LAD CV: tachy, regular, loud S2, 1-2/6 sys M at apex, no S3/S4 CHEST: rales at R base. no wheezes. ABD: NABS, soft, ND, no palpable masses, diffusely tender to palpation w/o rebound or guarding. RECTAL: Guaiac + black stool per ED note. EXT: no edema NEURO: A&Ox3, CN 2-12 intact bilat, sensory/motor exam intact bilat Pertinent Results: [2127-2-25] 09:24PM K+-3.9 [2127-2-25] 09:24PM HGB-12.3 calcHCT-37 [2127-2-25] 09:15PM GLUCOSE-100 UREA N-37* CREAT-0.5 SODIUM-129* POTASSIUM-4.8 CHLORIDE-91* TOTAL CO2-24 ANION GAP-19 [2127-2-25] 09:15PM estGFR-Using this [2127-2-25] 09:15PM ALT(SGPT)-44* AST(SGOT)-81* CK(CPK)-59 ALK PHOS-136* TOT BILI-0.3 [2127-2-25] 09:15PM CK-MB-NotDone [2127-2-25] 09:15PM cTropnT-<0.01 [2127-2-25] 09:15PM ALBUMIN-3.0* [2127-2-25] 09:15PM WBC-8.4 RBC-3.78* HGB-11.7* HCT-33.1* MCV-88 MCH-31.0 MCHC-35.5* RDW-14.9 [2127-2-25] 09:15PM NEUTS-78.2* LYMPHS-14.6* MONOS-7.0 EOS-0.2 BASOS-0.1 [2127-2-25] 09:15PM POIKILOCY-1+ [2127-2-25] 09:15PM PT-50.3* PTT-49.2* INR(PT)-6.0* [2127-2-25] 09:15PM PLT COUNT-551* . IMAGING: [2127-2-25] CXR: UPRIGHT AP CHEST: There is complete opacification of the left hemithorax, with mediastinal shift toward the left. The appearance suggests pneumonectomy or -- if there is no such history -- mucus plugging. Surgical clips are seen within the left chest. The left hemidiaphragm is elevated. The right lung is hyperexpanded and is clear. . [2127-2-26] CT ABD/PELVIS W/ & W/O: IMPRESSION: 1. 3.7-cm abdominal aortic aneurysm, infrarenal in location, with small amount of mural atheroma but no evidence of leak at this time. 2. Extensive intra- and extra-hepatic biliary ductal dilatation with pancreatic ductal dilatation. While no distinct abnormality is noted in the pancreatic head, this examination was not tailored for that purpose, and an ampullary process cannot be excluded. Correlation with any previous imaging is recommended. This could be further evaluated with ERCP or MRCP. 3. Two focal liver lesions, one measuring 1.9 cm that is incompletely characterized, it may represent a hemangioma. If further characterization is desired in this patient with history of cancer, MRI or multiphasic CT would be helpful. Second smaller lesion is too small to definitively characterize. 4. Diverticulosis. Small-to-moderate amount of free pelvic fluid. Limited assessment of the bowel on this examination without oral contrast. Findings were discussed by telephone with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at approximately 7:30 p.m. on the day of the examination. . [2127-2-28] EGD: Small hiatal hernia. Inlet patch in the proximal esopahgus. Erythema in the antrum and distal body of the stomach compatible with gastritis (biopsy). . [2127-2-28] Colonoscopy: Diverticulosis of the sigmoid colon. Otherwise normal colonoscopy to cecum. . PATHOLOGY: Gastrointestinal mucosal biopsies, four: A. Antrum: Changes consistent with chemical gastritis. B. Duodenum: No diagnostic abnormalities recognized. C. Ascending and transverse colon: Melanosis coli, otherwise within normal limits. Descending and sigmoid colon: Melanosis coli, otherwise within normal limits. . MRCP: [2127-3-2] 1. Small right pleural effusion and adjacent compressive atelectasis. 2. Intra and extrahepatic biliary ductal dilatation as well as pancreatic ductal dilatation. Differential diagnosis includes biliary stricture ampullary lesion, further evaluation with ERCP is recommended. There is a focal infrarenal abdominal aortic aneurysm with eccentric bulge of the aorta containing thrombus without definite inflammatory component seen at near the biliary ductal dilatation, this could be considered as a remote possibility of the cause of both pancreatic and hepatic ductal dilatation. 3. Chronic T12 compression fracture. 4. Right hepatic hemangioma and simple cyst. . RUQ U/S [2127-3-4]: Dilated intra- and extra-hepatic biliary ducts. No definite ampullary or pancreatic mass is identified. No choledocholithiasis identified. Brief Hospital Course: 72 yo F w/ h/o AAA, lung ca s/p lobectomy, brain ca s/p resection, A fib, and esophageal strictures s/p multiple dilations who presented with GI bleed and coagulopathy, initially admitted to the MICU and then transferred to the floor. . # GIB: Her hematocrit has stabilized. She received on unit PRBCs after admission on [2127-2-26]. She also received a total of 4 units of FFP while in the MICU to reverse her coagulopathy. Endoscopy and colonoscopy did not show obvious source of bleeding, with only gastritis and diverticulosis. Gastric biopsy taken. Her Hct remained stable without need for further blood transfusions. No further signs of active bleeding. . # Coagulopathy: Improved with Vit K given on admission. Has remained stable since that time. The etiology of her coagulopathy was unclear. She presented to the OSH with an elevated PT, PTT, and INR. This suggested an underlying factor deficiency or factor inhibitor vs. Vit K deficiency also possible [2-7] to malnutrition/malabsorption. DIC unlikely given elevated platelets and negative DIC labs. She denied coumadin use. INR was 1.2 at the time of discharge. . # Diarrhea: Her diarrhea slows with fasting which suggests non-secretory diarrhea. Had EGD on [2127-2-28] with biopsy. H. pylori vs. celiac disease are possibilities. She was placed on a gluten free diet. Colonic bx reveals e/o of melanosis coli (no h/o laxative use in patient). A TTG could be checked as an outpatient. . # Abd pain: The patient reports that this is a chronic problem. Unlikely due to chronic pancreatitis. AFP was 2.7. Has biliary and pancreatic ductal dilatation on prior CT. MRCP was done and also showed biliary ductal dilatation. 2 liver lesions visualized on CT appear to be c/w hemangioma and simple cyst on MRCP. AFP negative. LFTs normal. Patient was offered ERCP; however, refused the procedure. She wishes to transition to hospice care without further aggressive measures. . # NSTEMI: Initially, she ruled in for MI. EKG with nonspecific changes. Held BB and ASA in setting of GI bleed. Stared Lipitor 80mg daily, and followed LFTs. Enzymes eventually trended down. She remained chest pain free. . # AAA: Her AAA was diagnosed at OSH recently and reportedly seen on U/S (4.1cm). At OSH ED, she had a CT of the ABD which read this AAA as 5.11cm, without evidence of bleeding. After transfer to [Hospital1 18], vascular surgery evaluated her and recommend CTA of the abdomen, which showed her AAA is actually only 3.7cm. Vascular surgery signed off and recommended no further intervention. . # FEVER: Patient spiked fevers periodically on this admission. No clear infective source found. She denies pulm, urinary symptoms. No diarrhea, only N/V. Does have evidence of CBD dilatation, but LFTs have been normal and cholangitis seems unlikely. Initially covered with ceftriaxone and flagyl currently given GI source seems most probable although no definitive source even so. After patient decided to leave for skilled nursing facility with transition to hospice, patient was changed to empiric course of Cefpodoxime and flagyl PO for total 12 more days to complete her course. . # HYPONATREMIA: Seems most likely consistent with hypovolemic hyponatremia given poor PO intake, N/V, sinus tachycardia, and dry appearance on exam. Improved with IV hydration. . # PAIN CONTROL: Patient currently controlled with oxycontin 40mg [Hospital1 ] and morphine prn. . # FEN: Gluten free diet. . # COMM: [Name (NI) ] - [Name (NI) ] [Name (NI) 98852] [Telephone/Fax (1) 98853] . # DISPO: Patient was seen by the Palliative care consult team. After discussion with Palliative care and the medical team, she decided forgo further aggressive treatments. Per Dr. [Last Name (STitle) ] of the palliative care team, the patient "revealed she has already reached a decision on her own that she does not want any more aggressive intervention of any kind, and the option of transitioning to comfort measures instead is what she prefers. She welcomes the idea of Hospice care, and hopes that she may be able to go to a facility that can provide Hospice level care. She understands what Hospice care involves, as she was once a Hospice patient in the past until she rallied and signed off." . After this conversation, the patient was offered to a skilled nursing facility where she could be transitioned to hospice care. She accepted this transfer. . # CODE: DNR/DNI . Medications on Admission: MEDS ON ADMISSION: Nexium 40mg PO daily Dilantin 300mg PO QAM Neurontin 400mg PO BID Oxycontin 40 [Hospital1 ] Lorazepam 0.5mg PO Q8Hprn Konopin 0.5mg PO Q12H prn Zoloft 50 daily Mirtazapin 15 hs Lactulose 2-3tbsp /day Levoxyl 75mcg PO daily Lisinopril 25mg PO daily . MEDS ON TRANSFER FROM MICU: Levoxyl 75mcg PO daily Protonix 40 mg IV Q12 Gabapentin 400 mg [Hospital1 ] Mirtazapine 15 mg QHS Sertraline 50 mg Daily Atorvastatin 80 mg daily Dilantin 100 mg TID Oxycodone 40 mg Q12h Discharge Medications: 1. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 4. Oxycodone 40 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). 5. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO every 4-6 hours as needed for pain: Hold for sedation. 6. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for Agitation or nausea: Please give sublingual. 9. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 13. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 12 days. 14. Compazine 25 mg Suppository Sig: 0.5-1 tablet Rectal every six (6) hours as needed for nausea: Use if not tolerating PO compazine . 15. Compazine 10 mg Tablet Sig: 0.5-1 Tablet PO every six (6) hours as needed for nausea. 16. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) patch Transdermal Q72HR as needed for secretions. 17. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 12 days. Discharge Disposition: Extended Care Facility: [Hospital ] nursing home Discharge Diagnosis: PRIMARY: 1) Gastrointestinal bleeding 2) Coagulopathy 3) Abdominal Aortic Aneurysm 4) Non-ST elevation myocardial infarction 5) Hyponatremia 6) Fever SECONDARY: 1) lung cancer s/p left pneumonectomy 2) brain metastasis s/p resection 3) Atrial fibrillation Discharge Condition: Stable Discharge Instructions: Please take your medications as prescribed. Follow up with your skilled nursing facility regarding possibility of hospice care. Call your doctor if you have any concerns. Followup Instructions: Please discuss the possibility of hospice care with your skilled nursing facility. . Call your primary care doctor for a followup appointment after discharge.	[ "410.71", "427.31", "424.0", "441.4", "286.9", "V10.11", "780.6", "261", "280.0", "578.9", "276.1" ]	icd9cm	[ [ [] ] ]	[ "45.25", "45.16", "38.93" ]	icd9pcs	[ [ [] ] ]	13644, 13699	7030, 11508	275, 305	13999, 14008	3247, 7007	14229, 14391	2650, 2684		12050, 13621		13720, 13978		11534, 11539			14032, 14206									2699, 3228																								227, 237										333, 2007									11553, 12027						2029, 2522	2538, 2634
7,413	134,105	11380+56234	Discharge summary	report+addendum	Admission Date: [2172-11-4] Discharge Date: [2172-12-17] Date of Birth: [2117-3-1] Sex: M Service: Surgery HISTORY OF PRESENT ILLNESS: The patient presented with a history of type 2 diabetes, on insulin at baseline, admitted on [2172-11-4] for a Whipple procedure to stage a pancreatic mass. PAST MEDICAL HISTORY: 1. Type 2 diabetes mellitus. 2. Jaundice. 3. No known coronary artery disease. 4. No pancreatic insufficiency prior to present episode. MEDICATIONS ON ADMISSION: Morphine sulfate 20 mg and fentanyl. LABORATORY DATA: Prior to surgery, a CT scan showed no metastasis. Endoscopic retrograde cholangiopancreatography was done prior to surgery, with bile duct brushing negative for malignant cells; it showed common bile duct obstruction from a distal stricture and stents were placed at an outside hospital and the patient's painless jaundice resolved after placement of stents. ALLERGIES: The patient has no known drug allergies. HOSPITAL COURSE: On [2172-11-4], the patient was taken by Dr. [Last Name (STitle) 468] to the Operating Room to undergo a Whipple procedure. However, intraoperatively, the portal vein was lacerated and a Dacron graft was placed. During the operation, the estimated blood loss was 15 liters, requiring 33 liters of lactated Ringer's, 21 units of packed red blood cells, 4 units of fresh frozen plasma and 2 bags of platelets. The patient had a very stormy recovery course. Postoperatively, the patient was transferred to the Intensive Care Unit and required full ventilatory support on the ventilator. Due to his large transfusion, the patient was suffering from coagulopathy. Also, intraoperatively, due to the graft placement, a T-tube was placed at the bile duct and served as a drainage conduit. A pigtail catheter was placed outside the bile duct to drain out any biloma that was accumulating in the abdomen. A nasogastric tube was placed. A feeding jejunostomy tube was placed in the Operating Room. The patient was taken back to the Operating Room on [2172-11-7] for re-exploration and evacuation of the hematoma. The patient was taken back to the Surgical Intensive Care Unit postoperatively. Due to the patient's dependence on the ventilator, he underwent a tracheostomy in the Intensive Care Unit on postoperative day number ten. The patient was spiking fevers. Multiple CT scans were obtained and Citrobacter was grown out from the Dacron graft site. The patient was started on ciprofloxacin for 42 days, per the recommendation of infectious disease. This was started on [2172-11-13] to treat the Citrobacter at the graft infection. The patient was started on total parenteral nutrition to boost his nutritional status. A central line was placed. Total parenteral nutrition was continued until postoperative day number nine. On postoperative day number ten, the patient was started on tube feeds, initially at 10 cc/hour which the patient tolerated well. Tube feeds were continued and increased up to goal. During this time, the patient had developed some agitation and the patient was placed on a standing dose of Haldol to control his agitation. While in the Intensive Care Unit, we essentially administered supportive care. Eventually, on [2172-12-10], the patient condition was noted to be steadily improving and he was stable enough to be transferred on a regular floor. Prior to transfer, the patient had an echocardiogram which showed 4+ regurgitation. Cardiology was consulted prior to the Intensive Care Unit transfer and recommended cardiac medication for the congestive heart failure while in the Intensive Care Unit. The patient was transferred to the regular floor on [2172-12-11]. While on the floor, the patient was afebrile with stable vital signs. We obtained a swallow study on the patient and it appeared that the patient had begun to tolerate regular oral intake and the swallow study team had recommended to start the patient on a soft liquid diet. It was recommended that patient start on soft solids and regular liquids for a diet as tolerated. Meanwhile, we would continue the tube feeds. The patient's tracheostomy was decannulated on [2172-12-14] and the patient tolerated the decannulation well. Prior to discharge, he was breathing without the tracheostomy, saturating at 97% without any difficulties. Cardiology had scheduled the patient for an magnetic resonance angiogram to look at his coronary arteries. However, due to the patient's large body habitus and claustrophobia, the study could not be done. Cardiology recommended medication for the patient's 4+ regurgitation found on the echocardiogram. DISPOSITION: The patient is scheduled to be transferred to a rehabilitation facility on [2172-12-17]. DISCHARGE MEDICATIONS: Ciprofloxacin 500 mg p.o./per J-tube b.i.d., to end on [2172-12-23]. Ativan 1 mg p.o./per J-tube q.h.s. Aspirin 80 mg p.o./per J-tube q.d. Captopril 150 mg p.o./per J-tube t.i.d. NPH 38 units s.c.b.i.d. Criticare per J-tube 90 cc/hour. Magnesium oxide 800 mg p.o./per J-tube b.i.d. Coumadin 1 mg p.o./per J-tube q.d. Zantac 150 mg p.o./per J-tube b.i.d. Aldactone 2.5 mg p.o/per J-tube q.d. Digoxin 0.125 mg p.o./per J-tube q.d. Regular insulin sliding scale. DISCHARGE INSTRUCTIONS: Prior to transfer, the patient was instructed to have his INR level followed at the rehabilitation facility and to adjust the Coumadin level to achieve an INR goal of 2. The patient's diet status was a soft solids and regular liquid diet as tolerated. Meanwhile he is to have Criticare per jejunostomy tube at 90 cc/hour, also refeed with T-tube drainage and pigtail drainage. FOLLOW-UP: The patient was instructed to follow up with Dr. [Last Name (STitle) 468] in two weeks. DISCHARGE PHYSICAL EXAMINATION: The patient is afebrile with stable vital signs. Chest: Clear to auscultation bilaterally. Abdomen: Soft, nontender, incision healed, no drainage, no pus, T-tube in place, pigtail in place, jejunostomy tube in place. The patient is tolerating orals without aspiration [First Name8 (NamePattern2) 251] [Name8 (MD) ], M.D. [MD Number(1) 4984] Dictated By:[Name8 (MD) 186] MEDQUIST36 D: [2172-12-15] 12:50 T: [2172-12-15] 13:16 JOB#: [Job Number ] Name: [Known lastname 6495], [Known firstname ] Unit No: [Numeric Identifier 6496] Admission Date: [2172-11-4] Discharge Date: [2172-12-17] Date of Birth: [2117-3-1] Sex: M Service: GOLD [Doctor First Name 1379] ADDENDUM: Mr. [Known lastname ] is to be discharged to a rehabilitation facility on [2172-12-17]. However, addending to the discharge instructions, the patient is to be put on Digoxin 0.125 mg po q day, Aldactone 12.5 mg po / per jejunostomy tube q day, and Lasix 40 mg po / per jejunostomy tube q day per Cardiology recommendation. And per Cardiology recommendation, the ultimate goal for the patient is to after the patient becomes euvolemic, to be put on a low dose beta blocker to help out with congestive heart failure. Also, please check a Digoxin level and potassium level in two to three days, readjusting Lasix and Digoxin accordingly. The patient's Coumadin level is to be checked also. The patient will be discharged on Coumadin 1.5 mg po q day. Please readjust Coumadin level to the target range of 2.0. The patient needs to be followed up with his primary cardiologist in three to four weeks. If the patient does not already have a radiologist, he may come to see Dr. [First Name4 (NamePattern1) 1263] [Last Name (NamePattern1) ] at [Hospital3 ] - [Hospital ] [First Name (Titles) ] [Last Name (Titles) ]. Also, in terms of the patient's right pigtail drainage and right T-tube drainage care instruction, the combined sum of bilious drainage per day should be approximately 1-1.5 liters. If patient puts out less than that, please flush his pigtail and T-tube with 10 cc normal saline using a sterile fashion and the patient is to be re-saturated with the bile that is drained out from the T-tube or the pigtail. The patient is to be followed with Dr. [Last Name (STitle) 1099]. [First Name8 (NamePattern2) 116] [Name8 (MD) ], M.D. [MD Number(1) 4989] Dictated By:[Name8 (MD) 5162] MEDQUIST36 D: [2172-12-17] 08:55 T: [2172-12-18] 09:51 JOB#: [Job Number 6497]	[ "410.71", "425.4", "415.19", "998.0", "577.1", "996.62", "518.5", "997.4", "998.2" ]	icd9cm	[ [ [] ] ]	[ "44.39", "51.22", "31.1", "39.32", "52.7", "54.12", "44.69", "39.57", "96.33" ]	icd9pcs	[ [ [] ] ]									4829, 5294				524, 995	1013, 4806		5319, 5814																						5837, 8521																					169, 331															354, 497
27,967	170,148	32188+57788	Discharge summary	report+addendum	Admission Date: [2125-10-3] Discharge Date: [2125-10-9] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: chest tightness/ Severe LM disease Major Surgical or Invasive Procedure: emergent off pump CABGx4 (LIMA->LAD, SVG->OM, SVG->PLV->PDA) [10-3] History of Present Illness: 82 yo M with several weeks of fatigue, decreased exercise tolerance. Cath at OSH with severe LM disease. Transferred for surgical revascularization. Past Medical History: TIA, Arthritis, Gout, CRI (? Dialysis), Bladder tumor s/p resection Social History: -tob (quit 15 years ago) Family History: NC Physical Exam: NAD, Very HOH, afeb, 68 150/82 NCAT S1S2 CTAB, decreased at both bases Abd NT/ND No edema Pertinent Results: [2125-10-8] 07:45AM BLOOD WBC-8.1 RBC-3.34* Hgb-10.3* Hct-29.4* MCV-88 MCH-30.8 MCHC-35.0 RDW-14.7 Plt Ct-153 [2125-10-8] 07:45AM BLOOD Plt Ct-153 [2125-10-5] 02:41AM BLOOD PT-14.9* PTT-40.1* INR(PT)-1.3* [2125-10-9] 06:25AM BLOOD UreaN-37* Creat-1.6* K-4.5 [2125-10-8] 07:45AM BLOOD Glucose-83 UreaN-36* Creat-1.5* Na-144 K-3.6 Cl-108 HCO3-26 AnGap-14 CXR: Small bilateral pleural effusions greater in the left side are unchanged. The right lung is clear. Left lower lobe retrocardiac opacities consistent with atelectasis are persistent. Postoperative cardiomediastinal silhouette is unchanged. There is no pneumothorax. Approved: TUE [2125-10-9] 8:27 AM Brief Hospital Course: Mr. [Known lastname ] was transferred to [Hospital1 18] on [10-3] and he was taken to the operating room and underwent an off pump CABG x 4. He was transferred to the ICU in critical but stable condition. He was extubated and his vasoactive drips were weaned on POD #2. He developed gout in his left knee and was given colchicine. He was seen by physical therapy and rehab screening began. He was ready for discharge to rehab on POD #6. Medications on Admission: allopurinol, asa, atenolol, colchicine, folate, indomethacin, lipitor, plavix Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital 1294] Healthcare Center - [Location (un) 1294] Discharge Diagnosis: CAD TIA, Arthritis, Gout, CRI, Bladder tumor s/p resection Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No heavy lifting or driving until follow up with surgeon. Followup Instructions: Dr. [First Name (STitle) ] 1 month Dr. [Last Name (STitle) 4427] 2 weeks [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2125-10-9] Name: [Known lastname ],[Known firstname 12366] Unit No: [Numeric Identifier 12367] Admission Date: [2125-10-3] Discharge Date: [2125-10-9] Date of Birth: [2042-11-23] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 265] Addendum: Mr. [Known lastname ] should also follow up with his cardiologist Dr. [Last Name (STitle) 12368] in [2-24] weeks. Discharge Disposition: Extended Care Facility: [Hospital 3542] Healthcare Center - [Location (un) 3542] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 266] Completed by:[2125-10-17]	[ "274.9", "427.31", "414.01", "585.9" ]	icd9cm	[ [ [] ] ]	[ "89.64", "99.04", "36.15", "36.13" ]	icd9pcs	[ [ [] ] ]	4178, 4390	1541, 1991	302, 376	3137, 3145	834, 1518	3430, 4155	704, 708		2119, 2920		3055, 3116		2017, 2096			3169, 3407									723, 815																								228, 264										404, 554															576, 645	661, 688
7,187	175,644	17211	Discharge summary	report	Admission Date: [2161-6-7] Discharge Date: [2161-6-10] Date of Birth: [2078-11-19] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2745] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: Colonoscopy [2161-6-9] History of Present Illness: Ms. [Known lastname 13144] is an 82 yo F w/h/o stroke, CAD w/ stents, and diverticulosis, who presented for BRBPR. She was in her USOH until this afternoon at 12:30 pm when she developed painless, BRBPR of uncertain volume. She denied abd pain, N/V, F/C, cramping, diarrhea/constipation and CP/SOB. She went to the [Location (un) 620] ED where Hct was 35.2; she received 1L NC and nexium 20 mg IV x 1. She was then then was transferred to [Hospital1 18] for further care (specifically for angiography back-up capabilities). . Of note, she has had one prior episode of painless BRBPR in [4-/2161] for which she presented to [Location (un) 620] and had a colonoscoy. No source was identified: she was given supportive care with some RBC transfusions (though unclear how many; sounds like one) and she was discharged to a rehab facility. She also had a single polyp identified on colonoscopy which was not removed at the time. . In the [Hospital1 18] ED, VS were HR 104, BP 84/60, RR 22, 100% 2L NC. She was given 2 units RBC and 1 L NS for resuscitation. NG lavage was negative. The ED team spoke with GI who suggested a RBC scan if she opens up again; she has not been seen yet by GI. She has not had any more episodes since the ambulance ride from [Location (un) 620]; Hct was 35.2 on d/c from [Location (un) 620] and then 30.8 on arrival here. Baseline Hct is uncertain. Past Medical History: tobacco multiple falls (4 in last year), with broken vertebra 1y PTA Diveritculosis CAD-- s/p AMI, [Name Prefix (Prefixes) ] [Last Name (Prefixes) 10157] [2156] Stroke Anemia COPD HTN Arhtritis Social History: Significant tobacco use, unquantified No etoh No drugs She is currently living at home and gets home VNA and PT. She has five children; she was a homemaker. Family History: Noncontributory Physical Exam: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) 1060] [Last Name (NamePattern1) ] VS: Tcurrent 35.8 HR 89, BP 135/43, RR 18 , 93% 2L NC General Appearance: NAD, elderly, pale, Eyes / Conjunctiva: Conjunctiva pale Head, Ears, Nose, Throat: Normocephalic, Poor dentition Cardiovascular: normal S1/S2, no murmur Peripheral Vascular: 2+ radial, 2+ pedal pulses, warm, dry Respiratory / Chest: symmetric expansion, crackles at bases Abdominal: Soft, Non-tender, Bowel sounds present, Not Distended Musculoskeletal: Muscle wasting Skin: scattered ecchymoses Neurologic: attentive, oriented x 3; no focal deficits Pertinent Results: [2161-6-7] 6:12p 138 99 27 AGap=13 ------------<159 3.9 30 0.5 estGFR: >75 CK: 35 Trop-T: <0.01 ALT: 16 AP: 81 Tbili: 0.2 Alb: AST: 22 LDH: Dbili: TProt: CBC: 9.8 12.0>-----<282 30.8 N:64.6 L:30.0 M:4.3 E:0.8 Bas:0.2 Lactate 2.3 [2161-6-9] Colonoscopy) Diverticulosis of sigmoid and descending colon, otherwise nml colonoscopy. Brief Hospital Course: 82 yo F with diverticulosis, COPD, CAD on plavix/ASA at the time of admission presented with painless BRBPR. . #. LGIB: Most likely diverticular given painless nature and prior history. She had no further episodes since the early evening after arriving at [Hospital1 18]. In the ED, 2 units pRBC and 1L NS were administered and patient was transferred to the [Hospital Unit Name 153]. On arriving at the [Name (NI) 153] pt was hemodynamically stable. The decision was made to hold home antihypertensives and asa, plavix therapy. Pts hct was monitored overnight with no need for additional transfusions. In the morning GI was consulted. Colonoscopy was scheduled for the following morning which revealed diverticulosis of sigmoid and descending colon, otherwise normal, no evidence of active bleeding. Given history of two significant GI bleeds in the past month, patient's aspirin and plavix were held. Of note, pt has hx of drug-eluting coronary stents placed in [2156], anterior MI and CVA. She has strong indications for those meds, but given recent life-threatening GI bleed and from discussion with pt, her greatest current concern is recurrent GI bleed and she agrees with plan to hold ASA and plavix. At PCP f/u, re-evaluation rsik/benefit for aspirin and plavix should be made. # CAD: Pt denies and chest pain or cardiac symptoms. CE were negative. #. HTN: Pt was hypotensive on admission. Blood pressure normalized. Restarted home emds after colonoscopy. . #. COPD: Patient with history of COPD on supplemental oxygen at home. Pt breathing with pursed lips on admission. No home meds for COPD. CTA b/l on admission. Pt treated with atrovent/albuterol nebs. Pt given rx for advair and combivent on d/c. Outpt pulm f/u. Medications on Admission: Home medications: Plavix 75 mg, ASA 352 mg Prevacid 30 mg QD Iron sulfate 325 mg QD Diltiazem 30 mg QD HCTZ uncertain dose Vit D Discharge Medications: 1. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 3. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO once a day: Continue home med dose and frequency. 4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day: Continue home dose. 5. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO once a day. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 7. holding meds Sig: One (1) once a day: HOLDING PT'S plavix and ASA given recent significant GI bleed. At f/u PCP visit, [Name9 (PRE) 48258] whether to restart. 8. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. Disp:1 inhaler Refills:3 9. Combivent 18-103 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation four times a day as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:3 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Primary: Lower GI Bleed, anemia Secondary: COPD, Hypertension Discharge Condition: Vital Signs Stable Discharge Instructions: Return if having blood in one's stool, chest pain, dizziness, shortness of breath, significant weakness. DO NOT TAKE YOUR ASPIRIN OR PLAVIX FOR NOW. HOWEVER, YOU NEED TO FOLLOW-UP WITH YOUR PCP [Last Name (NamePattern4) ] 2 WEEKS TO REEVALUATE WHETHER YOU SHOULD RESTART ONE OR BOTH OF THOSE MEDS AT THAT TIME. Followup Instructions: Patient to f/u with PCP [Last Name (NamePattern4) ] 2 weeks.	[ "401.1", "V12.54", "562.12", "V45.82", "276.52", "496", "414.01", "285.1" ]	icd9cm	[ [ [] ] ]	[ "45.23", "99.04" ]	icd9pcs	[ [ [] ] ]	6282, 6331	3306, 5059	321, 350	6436, 6456	2898, 3283	6820, 6887	2213, 2230		5239, 6259		6352, 6415		5085, 5085			6480, 6797									2245, 2877					5103, 5216																			276, 283										378, 1793															1815, 2022	2038, 2197
48,123	102,489	35250	Discharge summary	report	Admission Date: [2171-3-21] Discharge Date: [2171-3-23] Date of Birth: [2137-6-17] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1257] Chief Complaint: Melena, bloody emesis Major Surgical or Invasive Procedure: EGD IR Venogram w/ stent placement History of Present Illness: This is a 33 year-old male with a history of [Male First Name (un) ]-Chiari Syndrome dx at age 12 with associated cirrhosis who presents with melena x3 days and emesis with blood streaks overnight. The patient has been having black stools over the last 3 days approx 2 episodes per day. He does not recall if there was blood, but perhaps a small amount. He reported abdominal pain that started yesterday, located left-side, lower abdomen and periumbilical. The pain is constant, crampy, [5-18]. He denied any fever or chills and has not noticed increase ascites. Of note the patient had a therapeutic paracentesis [1-16] during his admission for drainage of a breast hematoma. Today he developed one episode of emesis with blood streaks ("shot size" amount) prior to arrive to the ED. He has not had any prior GI bleeds since his portal caval shunt on [2170-7-17]. Denied NSAID use . In the ED, initial vital signs were Temp 98, HR:102, 120/81 RR: 12, 100%. The patient underwent NG lavage that showed coffee counds, small clots, minimal red blood that did not clear after 300ml. He was started on a octreotide and protonix gtt. His Hct was 39.2 (baseline 37-43), plts 176, INR: 1.5, leukocytosis 11.9, lactate 1.3. He was evaluated by Hepatology with plans for EGD. Two 18G PIV were placed and he received 500ml IVF. He remained hemodynamically stable in the ED and transferred to the MICU. . On arrival the patient has complaints of mild abdominal pain. Otherwise, no other complaints. Past Medical History: 1. Budd-Chiari Syndrome dx age 12 - c/b esophageal varices - first in [2164] w recurrent episodes - most recent EGD [6-16] w grade II and III esoph varices s/p banding. Also with portal hypertensive gastropathy - portocaval shunt [2170-8-17] 2. History of positive PPD, quantiferon +, s/p 9 months of INH treatment 3. s/p cholecystectomy Social History: Originally from El [Country 19118]. Adopted, moved to the United States at the age of 6 months. Former roofer, currently unemployed. Lives with his girlfriend. [Name (NI) ] does not smoke. Prior alcohol use but not active. Denies drug use. Family History: Adopted Physical Exam: Vitals: T 97.4, BP 113/71, P 81, RR 15, O2sat 99RA. GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, BS+, NT, ND EXT: No C/C/E, NEURO: AAOx3, nonfocal SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: Admission: [2171-3-21] 06:24AM BLOOD WBC-11.9# RBC-4.22 Hgb-13.4* Hct-39.2* MCV-93 MCH-31.6 MCHC-34.1 RDW-15.8* Plt Ct-176 [2171-3-21] 06:24AM BLOOD PT-16.5* PTT-34.4 INR(PT)-1.5* [2171-3-21] 06:24AM BLOOD Glucose-104* UreaN-33* Creat-1.1 Na-126* K-4.1 Cl-92* HCO3-26 AnGap-12 [2171-3-21] 06:24AM BLOOD ALT-85* AST-93* AlkPhos-325* TotBili-2.1* [2171-3-21] 06:24AM BLOOD Lipase-156* [2171-3-21] 06:31AM BLOOD Lactate-1.3 HELICOBACTER PYLORI ANTIBODY TEST (Final [2171-3-22]): NEGATIVE BY EIA. MRSA SCREEN (Final [2171-3-23]): No MRSA isolated. CXR ([2171-3-21]) Cardiomediastinal contours are normal. The lungs are clear. There is no pleural effusion or pneumothorax. RUQ US w/ Dopplers ([2171-3-22]) IMPRESSION: 1. Portacaval shunt is patent. 2. Known cirrhosis, splenomegaly and trace amount of ascites. Hepatic Venography ([2171-3-22]) Preliminary report.. Pressure gradient of 16 mmHg across shunt. Stent placed and then pressure of 10mmHg gradient observed. well placed stent. Brief Hospital Course: #. Upper GI Bleed: Pt with [Male First Name (un) ]-Chiari with cirrhosis s/p portal caval shunt in [7-17]. H/o of prior variceal bleeding, but no prior episodes since shunt was placed. The patient reported 3 days of melena and one episode of small amount of hematemsis. His Hct was 39.2 on admission and not significantly lower then his baseline. He has remained hemodynamically stable. He was started on a Protonix gtt and octreotide gtt in the ED. In the MICU he underwent EGD that showed esophageal varices that were not bleeding, hypertensive portal gastropathy and gastritis. There was not evidence of active bleeding. He was also given 1g CTX for SBP ppx. A ultrasound was performed to evaluate his shunt that showed a patent portocaval shunt. IR Venogram was performed showing a pressure gradient of 16 mmHg across shunt. A stent was placed and then a pressure gradient of 10mmHg wasobserved. Patient's Hct was 29.1 upon discharge, which should be followed up by his PCP. . #. Leukocytosis: On admission the patient had a leukocytosis, but denied fevers or chills. He did have complaints of lower abdominal pain. An abdominal U/S was performed that showed minimal ascites. His CXR did not show an infilrate and UA/CX was negative. . #. [Male First Name (un) ]-Chiari Syndrome: On admission the patient's MELD was 12 (MELD-Na 22). He has never been on anticoagulation. He is followed by Hepatology and has been evaluated for transplant. His lasix and spironolactone were held in the setting of his GI bleed. A stent was placed across his portacaval shunt with a final pressure of 10mmHg. . #. Hyponatermia: Pt with sodium of 126. He appeared dry on exam and likely represents hypovolemic hyponatermia. He was given IVF and sodium improved to 130, which should be followed up by his PCP. . #. [Last Name (un) ]: Pt with baseline Cr 0.6-0.8, but was elevated to 1.1 on admission. Likely pre-renal in the setting of vomiting, stools and lasix/spironolactone. On discharge his creatinine improved to 0.7. . Medications on Admission: Furosemide 80 mg Tab Daily Spironolactone 200 mg Daily Multivitamin (MAXIMUM DAILY GREEN) 5 mg-133 mcg daily Calcium Carb-Vit D3-Minerals 600 mg/400U 2 tab [Hospital1 ] Discharge Medications: 1. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 2. Multivitamin Oral 3. Calcium Oral Discharge Disposition: Home Discharge Diagnosis: Primary: Upper GI Bleed Secondary: [Male First Name (un) ]-Chiari Syndrome Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted to the hospital with a upper gastrointestinal bleed. A scope revealed there was no active bleeding in your gut, however there are changes to the lining of your stomach. These changes are a complication of the high pressure in your liver. The shunt in your liver was opened further with a stent to make sure there would be no backup of blood. Some of your lab tests were also low including your sodium, which is why your diuretics were stopped. Your blood level was also low likely due to your blood lost. You should NOT take your diuretics: Furosemide and Spirinolactone. Please follow up with your primary care doctor in the next week to go over your lab tests [Last Name (LF) ],[First Name3 (LF) ] [Telephone/Fax (1) 80428] You should also call the Liver Center: ([Telephone/Fax (1) 29435] to set up "Right Upper Quadrant Ultrasound with Dopplers" next week. You will also need to set up a colonoscopy in the near future. Followup Instructions: Please follow up with: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 13999], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2171-3-27] 4:00 Provider: [Name10 (NameIs) ] Phone:[Telephone/Fax (1) 62] Date/Time:[2171-4-9] 2:00 Provider: [Name10 (NameIs) 706] MRI Phone:[Telephone/Fax (1) 327] Date/Time:[2171-4-9] 3:35 Completed by:[2171-3-25]	[ "276.1", "V45.89", "584.9", "456.21", "E878.8", "537.89", "453.0", "571.5", "996.74", "288.60", "535.50", "789.59", "572.3" ]	icd9cm	[ [ [] ] ]	[ "96.34", "45.13", "00.40", "39.50", "39.90", "88.64", "00.45", "88.51" ]	icd9pcs	[ [ [] ] ]	6653, 6659	4156, 6199	337, 374	6783, 6783	3086, 4133	7917, 8323	2575, 2584		6422, 6630		6680, 6762		6225, 6399			6928, 7894									2599, 3067																								276, 299										402, 1918											6797, 6904				1940, 2292	2308, 2559
43,093	193,466	18076	Discharge summary	report	Admission Date: [2200-7-30] Discharge Date: [2200-8-3] Date of Birth: [2128-10-11] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2782] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: [2200-7-30] right IJ central line placement History of Present Illness: 71 year old Haitian-Creole female with history of CVA, HTN/HL, breast CA in remission, presumed CHF (on furosemide), and type 2 DM presenting with altered mental status from home. Her daughter and grand-daughter provided much of the following history. The patient started to feel poorly 2 days PTA, when she started vomiting from an unknown cause. Since that time, she had become progressively less responsive and was weak on her feet. She is normally able to get around with a cane or a walker, ascend stairs, and walk independently. However, she had difficulty even standing up. She did not eat or drink anything since vomiting. She intermittently complains of abdominal pain of fleeting character, but denies any urinary symptoms. She has a history of GI bleeding, per the family, which they describe as "mixed red and black". Her last "bloody" stool was about 2 weeks ago. No associated falls or trauma. No recent medication changes. She recently visited her PCP within the past 2 weeks and was due to return shortly to follow-up on her medications and chronic conditions. In the ED, initial vitals were: 98.7 53 100/53 18 96% on 2L. Initial EKG shows ?complete AV block, prompting concern for CCB toxicity and treatment with calcium gluconate + glucagon. Subsequent EKGs showed 1st degree AV at a rate of 60bpm. However, she remained hypotensive (lowest [Location (un) 1131] 63/50) and had very difficult access, prompting insertion of an 18GA L EJ and a RIJ triple lumen CVL. After 1.5L NS (creatinine 3.7, unknown baseline) and 1 units pRBCs (Hct 21.6, unknown baseline), CVP was measured at 22. Guaiac negative. CT head and CT abd/pelvis did not show any acute bleeding. CXR clear of infiltrate with evidence of cardiomegaly in AP view. She was seen by Cardiology in the ED who felt that her acute kidney injury may have led to decreased clearance of diltiazem resulting in AV nodal blockade, which spontaneously resolved. They recommended aggressive fluid resuscitation to assess BP response and monitoring on telemetry, with admission to MICU for further work-up. On arrival to the MICU, she was normotensive and no longer bradycardic, still disoriented and picking at her central line. She is not in any pain. 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, diarrhea, constipation, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - Hypertension / hyperlipidemia - Breast cancer Stage II, s/p lumpectomy [2192] and radiation, now in remission - Esophageal reflux - EGD [3-3] showed mild gastritis - Diabetes mellitus, type 2 - CVA x3 in ~[2193]-[2194] (left sided weakness, mental clarity fluctuates) - Back pain, secondary to sciatic pain on right side and degenerative disc disease, spinal stenosis. Seen at Pain Clinic since [2192] s/p injections, chronic opioid use - Postmenopausal bleeding with endometrial polyp [2192], fibroid uterus - Osteoporosis in spine, on Fosamax/vit d - Adenomatous colonic polyps (c-scope [2198-5-24]) Social History: Originally from [Country 2045], moved to US in [2177], family not affected by [2197] Quake. Living situation: lives with husband, 2 involved daughters. Language: Haitian Creole. Smoking: denies. Alcohol: denies. Exercise: sedentary. ADLs: Able to dress herself, but requires assistance with bathing, grooming, and cooking, for which family assists and they have hired help as well. This has been the case since her CVA 5-6 years ago. Family History: HTN, DM2 in most of family; malignancy in her niece of unknown origin No hx of colon ca. Physical Exam: Admission Physcial Exam: Vitals: T: 98.1 BP: 117/56 P: 74 R: 18 O2: 100% RA General: AAOx1, disoriented to place and time HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not appreciated, no LAD; RIJ CVL in place CV: Regular rate and rhythm, normal S1 + S2 but soft, no murmurs, rubs, gallops Lungs: very mild bibasilar crackles, no wheezes or rhonchi Abdomen: soft, non-tender, mildly distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing or cyanosis, 1+ edema Neuro: CNII-XII intact, 4/5 strength upper/lower extremities bilaterally, grossly normal sensation Discharge Physical Exam: VS - 98.5 130/67 72 18 100%RA BS: 108 I: 1180 O: 1100+ GENERAL - NAD, standing at bedside HEENT - NC/AT, EOMI without nystagmus, sclerae anicteric, MMM NECK - supple, no LAD appreciated HEART - RR, nl S1-S2, no MRG LUNGS - Clear in apices bilaterally. Decreased air entry at bases bilaterally with rales. ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, 1+ pitting edema bilaterally, 1+ radial pulses SKIN - Several scattered small (2-3mm) circular hyperpigmented spots on R ankle. NEURO - awake, A&Ox1 (knows name only) Pertinent Results: Admission Labs: [2200-7-30] 06:50PM BLOOD WBC-9.4 RBC-2.38# Hgb-6.8# Hct-21.6# MCV-91# MCH-28.5# MCHC-31.3 RDW-14.9 Plt Ct-332# [2200-7-30] 06:50PM BLOOD Neuts-71.0 Lymphs-20.1 Monos-7.1 Eos-1.7 Baso-0.2 [2200-7-30] 06:50PM BLOOD PT-12.0 PTT-23.9* INR(PT)-1.1 [2200-7-30] 06:50PM BLOOD Ret Man-1.6* [2200-7-30] 06:50PM BLOOD Glucose-117* UreaN-42* Creat-3.7# Na-139 K-3.6 Cl-102 HCO3-27 AnGap-14 [2200-7-30] 06:50PM BLOOD LD(LDH)-145 TotBili-0.2 [2200-7-30] 06:50PM BLOOD cTropnT-<0.01 [2200-7-30] 06:50PM BLOOD Calcium-8.5 Phos-5.3# Mg-2.4 [2200-7-30] 06:50PM BLOOD Hapto-335* [2200-7-30] 07:16PM BLOOD Type-[Last Name (un) ] pO2-47* pCO2-48* pH-7.33* calTCO2-26 Base XS--1 Comment-GREEN TOP [2200-7-30] 07:16PM BLOOD Lactate-1.8 CBC: [2200-7-31] 01:47AM BLOOD WBC-13.0* RBC-2.67* Hgb-7.7* Hct-23.8* MCV-89 MCH-28.7 MCHC-32.3 RDW-15.8* Plt Ct-264 [2200-8-1] 05:19AM BLOOD WBC-9.6 RBC-2.66* Hgb-7.6* Hct-23.9* MCV-90 MCH-28.6 MCHC-31.8 RDW-15.8* Plt Ct-263 [2200-8-1] 02:45PM BLOOD WBC-9.3 RBC-2.58* Hgb-7.7* Hct-23.4* MCV-91 MCH-29.8 MCHC-33.0 RDW-16.0* Plt Ct-246 [2200-8-2] 07:50AM BLOOD WBC-8.5 RBC-2.83* Hgb-8.0* Hct-25.5* MCV-90 MCH-28.4 MCHC-31.5 RDW-16.1* Plt Ct-260 [2200-8-3] 10:15AM BLOOD WBC-8.7 RBC-3.05* Hgb-8.7* Hct-27.9* MCV-91 MCH-28.5 MCHC-31.1 RDW-16.3* Plt Ct-274 [2200-7-31] 01:47AM BLOOD Neuts-76.2* Lymphs-18.3 Monos-4.5 Eos-0.9 Baso-0.1 COAGULATION PANEL: [2200-7-31] 01:47AM BLOOD PT-12.3 PTT-26.4 INR(PT)-1.1 [2200-7-30] 06:50PM BLOOD Ret Man-1.6* CHEMISTRY: [2200-7-31] 01:47AM BLOOD Glucose-85 UreaN-38* Creat-2.9* Na-141 K-3.4 Cl-108 HCO3-24 AnGap-12 [2200-8-1] 05:19AM BLOOD Glucose-105* UreaN-23* Creat-1.6# Na-141 K-3.5 Cl-107 HCO3-26 AnGap-12 [2200-8-2] 07:50AM BLOOD Glucose-102 UreaN-15 Creat-1.2* Na-140 K-4.2 Cl-107 HCO3-23 AnGap-14 [2200-8-3] 10:15AM BLOOD Glucose-163* UreaN-12 Creat-1.1 Na-141 K-4.1 Cl-107 HCO3-24 AnGap-14 [2200-7-31] 01:47AM BLOOD Calcium-8.8 Phos-4.7* Mg-2.2 [2200-8-1] 05:19AM BLOOD Calcium-8.7 Phos-3.1# Mg-1.8 [2200-8-2] 07:50AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.9 [2200-8-3] 10:15AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.9 OTHER LABS: [2200-7-30] 06:50PM BLOOD LD(LDH)-145 TotBili-0.2 [2200-8-1] 05:19AM BLOOD CK(CPK)-548* [2200-8-1] 05:19AM BLOOD CK-MB-2 cTropnT-<0.01 [2200-8-1] 05:19AM BLOOD D-Dimer-5947* [2200-7-30] 06:50PM BLOOD Hapto-335* DIABETES MONITORING: [2200-7-31] 01:47AM BLOOD %HbA1c-8.7* eAG-203* BLOOD GAS: [2200-7-30] 07:16PM BLOOD Type-[Last Name (un) ] pO2-47* pCO2-48* pH-7.33* calTCO2-26 Base XS--1 Comment-GREEN TOP [2200-7-30] 07:16PM BLOOD Lactate-1.8 URINE: [2200-7-31] 01:47AM URINE Eos-NEGATIVE [2200-7-31] 01:47AM URINE CastHy-4* [2200-7-31] 01:47AM URINE RBC-1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-<1 [2200-7-31] 09:49PM URINE RBC-10* WBC-3 Bacteri-NONE Yeast-NONE Epi-<1 [2200-7-31] 01:47AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [2200-7-31] 09:49PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM [2200-7-30] 09:30PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.012 [2200-7-31] 01:47AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.009 [2200-7-31] 09:49PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.011 MICRO: Blood cultures [2200-7-31]: pending Blood cultures [2200-7-30]: pending MRSA screening [2200-7-31]: negative Urine culture [2200-7-31]: no growth IMAGING: CXR [2200-7-31]: IMPRESSION: 1. Right lung base early pneumonia or atelectasis. Early pneumonia is the preferred diagnosis in the appropriate clinical setting. 2. Engorgement of the mediastinal vessels consistent with increased central venous pressure. 3. Stable chronic cardiomegaly and enlarged aorta. CT HEAD WITHOUT CONTRAST [2200-7-31]: There is no hemorrhage, mass, mass effect, or acute large territorial infarction. A focal hypodensity within the right cerebellum is suggestive of prior infarct. Additionally, a hypodense lesion within the left thalamus is suggestive of prior lacunar infarct. Moderate periventricular hypoattenuation is unchanged from prior, and suggestive of chronic small vessel ischemic changes. Mild proportional enlargement of the ventricles and sulci is consistent with age-related cortical atrophy. There is no shift of the usually midline structures. Suprasellar and basilar cisterns are widely patent. There is no scalp hematoma or osseous fracture or lesion. The visualized paranasal sinuses and mastoid air cells are well aerated. BILATERAL LOWER EXTREMITY ULTRASOUND [2200-7-31]: No evidence of DVT. ECHO [2200-7-31]: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF 65%). The right ventricular free wall thickness is normal. The right ventricular cavity is dilated with severe global free wall hypokinesis. There are complex (>4mm) atheroma in the aortic arch. There are focal calcifications in the aortic arch. The number of aortic valve leaflets cannot be determined. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. 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 findings of the prior study (images reviewed) of [2196-8-8], the right ventricle is now dilated and hypocontractile, although there may have been some dysfunction of the right ventricle in the prior study. CT ABD/PELVIS W/O CONTRAST [2200-7-30] IMPRESSION: 1. No evidence of free fluid or retroperitoneal hematoma; normal size of the aorta. 2. Left breast mass as described above, indeterminate - correlate with prior breast imaging. 3. Multiple indeterminate renal lesions, some of which are cysts, but some of which are solid; MR may be considered if clinically warranted. CT HEAD W/O CONTRAST [2200-7-30]: IMPRESSION: No acute intracranial process. CXR [2200-7-30]: Moderate cardiomegaly, otherwise no acute cardiopulmonary pathology. Brief Hospital Course: CHIEF COMPLAINT: Altered mental status REASON FOR ADMISSION: 71 year old Haitian-Creole female with history of prior CVA, HTN/HL, presumed CHF, and type 2 DM, admitted with altered mental status, hypotension from presumed calcium-channel toxicity due to acute kidney injury, and concomitant anemia of unclear etiology. ACTIVES ISSUES BY PROBLEM: # Hypotension: On admission, the patient was found to be hypotensive to SBP 60s and bradycardic to HR 50s, with EKG showing junctional escape rhythm. The patient was evaluated by cardiology. In the setting of acute kidney injury, hemodynamic parameters thought to be due to calcium channel toxicity. the patient was treated with IV fluids and holding her diltiazem. Despite spontaneous return to 1st degree AV block, hypotension initially persisted. She underwent ECHO in the ICU that showed newly worsened free wall hypokinesis of her right ventricle from prior in [2195]. (see right ventricular dysfunction below). BP returned to [Location 213] range with IV fluids. Only low dose lisinopril was restarted on discharge, all other medications continued to be held. These can be restarted at the discretion of her PCP. # Acute kidney injury: The patient was admitted with a creatinine of 3.7 from unknown baseline. Renal failure likely due to a combination of prerenal azotemia from hypovolemia (?blood loss leading to anemia and dehydration from poor PO intake + vomiting) and intrinsic renal disease. FEUrea 39%. Urinalysis negative for UTI. Creatinine returned to [Location 213] range with IV fluid administration. # Right ventricle dysfunction: An echo revealed dilation of the right ventricle and hypokinesis of the right free wall, new since last echo in [2195]. Hypokinesis may represent new interval ischemic event or be the result of obstructive physiology (such as PE). She did not complain of chest pain or shortness of breath, and her EKG and cardiac enzymes did not show evidence of ACS. Given suspicion for pulmonary embolus, a ddimer was obtained and was >5000. LENIS showed no evidence of DVT. A CTA was deferred in the context of her recent [Last Name (un) ]. Furthermore, were an embolus found, it is unlikely that anticoagulation would be started in the setting of reported recent GI bleeding. A V/Q scan was considered but deferred in the setting of her abnormal CXR. It is recommended that she have follow-up as an outpatient to determine the cause of this new finding. # Pneumonia. Upon admission to the medicine floor, she was febrile to 101 with a WBC of 13. She denied cough or SOB, however, her CXR was concerning for a right sided pneumonia. She was started on levofloxacin for community acquired pneumonia. She did not have any further fevers, and given absence of clinical signs of pneumonia, this medication was discontinued before discharge. # Arrhythmia. Patient was admitted with bradycardia and an EKG suggestive of a junctional rhythm in the setting of possible. She was given calcium gluconate and glucagon in addition to IVF, leading to return of sinus rhythm with a prolonged PR. She was monitored on telemetry and had no further arrhythmias. # Anemia: Patient was admitted with a HCT of 21 and history of grossly bloody stools 2 weeks prior to admission. Baseline HCT unknown. She was found to be guaiac negative in the emergency department. Her retic count was 1.6, showing inappropriate response to degree of anemia. Renal failure is a possible cause of anemia, but would have to be much longer standing. Hemolysis labs were negative. The patient was transfused 1 unit PRBCs, and her HCT continued to improve during the admission. She was started on iron supplementation. She should be followed in the outpatient setting. # Altered mental status. As patient was more confused than baseline per family, she underwent two non-contrast CTs of the brain. No acute intracranial process was identified. She was evaluated by neurology, who recommended EEG to rule out non-status epilepticus, which was normal. They believe her AMS was caused by acute toxic metabolic causes, and her mental status improved to baseline by discharge. # Diabetes mellitus, type 2: Patient takes only oral medications at home and has never been on insulin. Januvia and glimepiride were held in the setting of [Last Name (un) ]. Insulin sliding scale was initiated. Her HbA1c was 8.7, indicating poor control of her blood sugar. # Hypertension: Anti-hypertensives were held given hypotension and renal failure described above. # Hyperlipidemia: The patient was continued on atorvastatin. # Deconditioning: She was evaluated by physical therapy, who felt that she would benefit from rehabilitation. Her family opted for discharge home with with physical therapy services given their prior experiences at rehab facilities. # Breast cancer: A spiculated mass was demonstrated in the L breast on CT, consistent with her history of L lumpectomy for stage II breast cancer. Her PCP and oncologist were made aware, and she should have continued monitoring in the outpatient setting. TRANSITIONAL ISSUES: -Right ventricle dysfunction: A new finding on echo. Patient may need outpatient cardiology followup, to be dertermined by PCP [Name Initial (NameIs) 50018]: Patient's home BP meds were held during admission, and she was only restarted on 10mg lisiopril daily. She will need to be restarted on other meds as her PCP sees appropriate. -Deconditioning: Patient will require home physical therapy -History of breast cancer with spiculated L breast mass: She will need continued monitoring, and oncologist and PCP were made aware. MEDICATION CHANGES: START iron 325mg daily STOP diltiazem STOP lasix Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver. 1. Lisinopril 40 mg PO DAILY 2. Diltiazem Extended-Release 300 mg PO DAILY 3. Furosemide 60 mg PO DAILY 4. Atorvastatin 40 mg PO DAILY 5. Amaryl NF (glimepiride) 2 mg Oral [Hospital1 ] 6. Januvia NF (sitaGLIPtin) 100 mg Oral daily 7. Alendronate Sodium Dose is Unknown PO Frequency is Unknown 8. Pantoprazole 40 mg PO Q12H 9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 10. Calcium Carbonate 600 mg PO DAILY 11. Vitamin D 200 UNIT PO DAILY 12. Timolol Maleate 0.5% 1 DROP BOTH EYES [Hospital1 ] Discharge Medications: 1. Atorvastatin 40 mg PO DAILY 2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 3. Timolol Maleate 0.5% 1 DROP BOTH EYES [Hospital1 ] 4. Alendronate Sodium 0 mg PO UNDEFINED 5. Pantoprazole 40 mg PO Q12H 6. Ferrous Sulfate 325 mg PO DAILY RX ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 7. Calcium Carbonate 600 mg PO DAILY 8. Vitamin D 200 UNIT PO DAILY 9. Amaryl NF* (glimepiride) 2 mg ORAL [Hospital1 ] Do not take this medication if you are not eating, as it can cause low blood sugars 10. Januvia NF (sitaGLIPtin) 100 mg Oral daily 11. Lisinopril 10 mg PO DAILY RX lisinopril 10 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: Acute Kidney Injury Hypotension Right heart failure acute Community acquired pneumonia Altered mental status Arrythmia Anemia Diabetes Mellitus (Type II) Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mrs. [Known lastname ], It was a pleasure being involved in your care at [Hospital1 18]. You were admitted for confusion and not feeling well at home. You were found to have very low blood pressure, a slow heart rate, damage to your kidneys that required admission to the intensive care unit. You were also found to be anemic and required a blood transfusion. Your blood pressures, heart rate, and kidney function all improved with fluids. We believe that your vomiting and poor oral intake at home led to dehydration, and that your blood pressure medicines worsened your condition and cause the low blood pressures and kidney damage. These medicines were held while you were in the hospital. We are restarting one of them, lisinopril, at a lower dose. You should not take the diltiazem or furosemide until follow-up with your primary care doctor to decide how to best manage your blood pressure without causing these problems again. You also had very low blood counts, which we think is from bleeding from your GI tract, as you have had some blood in your stools in the past few weeks. It is very important that your primary doctor monitors these blood levels and has further discussions with you and your family about following up with a GI doctor for some further testing (like a colonoscopy or endoscopy) to determine the source of bleeding. In the meantime, you were started on iron supplements for this anemia. An ultrasound of your heart showed an abnormal right ventricle, which is a new finding since your last ultrasound in [2195]. You should follow-up with your doctor, as we recommend further investigation into the cause of this abnormality. We discussed getting a CT scan with contrast of your lungs to look for blood clots, but you didn't want to get this while in the hospital. According to your family, you were more confused than usual on admission. Imaging of your brain revealed evidence of old strokes, but no evidence of new strokes. A measurement of the electrical activity of your brain showed no seizures. We think your confusion was simply caused by how sick you were when you were admitted, and it improved as your medical problems improved. [Name2 (NI) ] had an EEG (electroencephalogram) while in the hospital. The results of this were still pending before you left and will need to be followed up by your PCP. You developed a fever in the hospital and had an elevated white blood count, which can be a sign of infection. Your chest x-ray showed a possible pneumonia, and you were started ([2200-7-31]) on an antibiotic called levofloxacin, however you did not have a cough or other signs of pneumonia so we are stopping this medicine. Your Type II diabetes does not appear to be well-controlled. Your HbA1c is 8.7. Your home oral medications were held during your admission given your kidney injury, but these can be restarted when you go home. You should continue blood glucose monitoring and have follow-up with your primary care doctor. You were also evaluated by physical therapy, who recommended going home with physical therapy. Followup Instructions: Please call your PCP [Last Name (NamePattern4) ].[Name (NI) 50019] office at [Telephone/Fax (1) 50020] to make an appointment to be seen within the next week for follow up after your hospitalization. Other upcoming appointments: Department: [Hospital3 1935] CENTER When: WEDNESDAY [2200-9-24] at 11:00 AM With: [Name6 (MD) 251] [Last Name (NamePattern4) 252], M.D. [Telephone/Fax (1) 253] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23*] Garage	[ "V10.3", "428.0", "438.22", "536.3", "458.29", "733.00", "E942.4", "584.9", "401.9", "348.31", "272.4", "294.20", "427.89", "285.1", "276.51", "250.62" ]	icd9cm	[ [ [] ] ]	[ "38.97" ]	icd9pcs	[ [ [] ] ]	19084, 19090	11965, 11965	326, 376	19307, 19307	5576, 5576	22613, 23179	4221, 4311		18352, 19061		19111, 19286		17705, 18329			19482, 22590									4326, 4974																	17076, 17608		2663, 3084		17628, 17679			11982, 17055										404, 2644							5592, 7781				19322, 19458				3106, 3740	3756, 4205			7793, 11942	4999, 5557
15,450	193,597	13471	Discharge summary	report	Admission Date: [2147-7-3] Discharge Date: [2147-7-4] Date of Birth: [2083-3-26] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2704] Chief Complaint: Transfer from [Hospital6 33] after PEA arrest in the field Major Surgical or Invasive Procedure: none History of Present Illness: History obtained from OSH and prior [Hospital1 ] records. This is a 64 year-old man with a history of CAD s/p CABG in [2135], left main and left circ stents by Dr. [Name (NI) ], unclear dates, chf with depressed left ventricular systolic function, ef 35%, dm, carotid artery disease, pvd, subclavian stenosis s/p stents transferred from [Hospital6 33] after having PEA arrest at home. Patient reported to his wife feeling like he was going to die and subsequently lost consciousness. EMS summoned by wife. According to EMS report, patient without pulse or respiration, full ALS initiated, patient intubated in the field, multiple rounds of epi and atropeine administered. Brought to ER with cpr in progress, PEA. Ultimately regained pulse. Conflicting reports as to amount of time down 8-25 minutes. At [Hospital3 ] his ECG reportedly (no ekg's sent with wide complex tachycardia) initially showed a wide complex tachycardia, with RBBB, LPFblock, st depr in I and avl and old anteroseptal MI. He was given amio 300mg IV and then developed a junctional rhythm with no pulse and required repeated resucitation. He was placed on a levophed drip and an echocardiogram was performed. It showed inferobasilar infarct, dilated left ventricle, small pericardial effusion. Found to have a marked metabolic acidosis. Runs of NSVT. Head CT without acute CNS event. Possible seizure activity noted. He was seen by cardiology who felt acute MI was unlikely, data consistent with old MI Also seen by neurology who was concerned for anoxic encephalopathy and secondary seizure activity and recommended seizure prophylaxis with fosphenytoin and support for 24-48 to allow for further assessment of anoxic injury. Poor prognosis. Patient has not regained conscousness since the arrest, unresponsive to noxious stimuli and was noted to have focal twitching of face and arms. Past Medical History: 1.CAD; s/p MI/ CABG [2135] 2.CHF; EF=35% [2145-5-25] 3.Type 2 DM 4.Hypercholesterolemia 5.Gout 6.Sleep apnea; using CPAP 7.Morbid obesity 8.Rheumatoid arthritis; on methotrexate 9.PVD 10.Left DVT [2145-6-5] ->coumadin Social History: Lives with his wife. Ambulates with left leg prosthesis. He does not smoke cigarettes. He occasionally drinks alcohol. Family History: Noncontributory. Physical Exam: VS: Temp: 98.2 BP:166/69 on levophed HR:82 vent: AC, TV 700 rr14 fio20.6 peep 10 100%saturation ABG pending . general: intubated, sedated, not responsive to noxious stimuli, obese, patient with apparent hiccups, also facial and eye twitching consistent with seizure activity HEENT: pupils are non-reactive, anicteric, ogtube in place draining foul smelling fluid, diff to assess jvp secondary to obesity Right subclavian line in place lungs: coarse sounds throughout, no crackles appreciated heart: RR, distant heart sounds-no murmurs appreciated abdomen: obese, hypoactive b/s, soft, nt extremities: above knee amputation on left, multiple scars from surgeries, 1+edema in right, venous insuffiency changes, right radial aline in place skin/nails: multiple ecchymosis neuro: intubated, sedated, not responsive to noxious stimuli rectal: draining liquid stool Pertinent Results: [2147-7-3] 03:55AM PT-18.0* PTT-32.7 INR(PT)-1.7* [2147-7-3] 03:55AM PLT SMR-LOW PLT COUNT-71# [2147-7-3] 03:55AM NEUTS-76 BANDS-9* LYMPHS-6* MONOS-4 EOS-1 BASOS-0 ATYPS-1* METAS-2* MYELOS-1* BLASTS-0 NUC RBCS-5* [2147-7-3] 03:55AM WBC-12.8* RBC-3.04* HGB-9.2* HCT-28.6* MCV-94 MCH-30.3 MCHC-32.2 RDW-18.8* [2147-7-3] 03:55AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2147-7-3] 03:55AM TSH-4.3* [2147-7-3] 03:55AM CALCIUM-8.7 PHOSPHATE-5.6# MAGNESIUM-2.0 [2147-7-3] 03:55AM CK-MB-12 MB INDX-7.0* [2147-7-3] 03:55AM cTropnT-0.47* [2147-7-3] 03:55AM ALT(SGPT)-35 AST(SGOT)-100* CK(CPK)-171 TOT BILI-0.8 [2147-7-3] 03:55AM GLUCOSE-247* UREA N-105* CREAT-3.4# SODIUM-140 POTASSIUM-5.6 CHLORIDE-111* TOTAL CO2-15* ANION GAP-20 [2147-7-3] 04:07AM freeCa-1.18 [2147-7-3] 04:07AM LACTATE-1.9 K+-5.3 [2147-7-3] 04:07AM TYPE-ART TEMP-36.8 PO2-238* PCO2-27* PH-7.35 TOTAL CO2-16* BASE XS--8 [2147-7-3] 07:40AM URINE AMORPH-MOD [2147-7-3] 07:40AM URINE RBC-21-50* WBC-[6-3]* BACTERIA-0 YEAST-NONE EPI-[2-26] EKG:Old: from [2144] showed sinus rhythm, lvh, ST depr in I avl V5, V6, q's with persistent st elevation v1-v3 EKG from OSH shows junctional, rbbb with lpfblock and again st depr laterally and old q's/ste anteriorly EKG here--again sinus, ivcd, lvh, st depr in I, l, V5, 6, q's with persistent st elevation v1-v3. Brief Hospital Course: This is a 64 year-old man with history of CAD s/p CABG and stents, carotid, subclavian and pvd, dm, cri transferred from [Hospital1 34] after pea arrest [7-2] afternoon at home. Now intubated, on levophed with no response to noxious stimuli and non-reactive pupils. S/p arrest: Unclear etiology, primary cardiac event vs. metabolic causes given CAD and CRI. EKG's do not show evidence of new event, more consistent with old MI's. Enzymes unimpressive from OSH for infarct--trop of 0.43 s/p arrest with negative CK and MB. Head CT negative at OSH. was on pressor and ventilatory support. also on fosphenytoin as reportedly had seizure activity at [Hospital1 34] and was seen by neuro who recommended fosphenytoin. CV: ischemia: significant CAD history as noted, unclear if had another event but ekg, echo done at [Hospital1 34] consistent with old MI's, enzymes unimpressive and in setting of s/p arrest. CK neg x 3. trop +ve x 3. continued on aspirin, plavix, statin. no beta, ace given hypotension/need for pressor support. pump: hypotension: history of depressed ef, appeared to be mildly fluid overloaded, hypotensive-was on pressor support. neuro cause vs. card shock.; continued on pressor support rhythm: no acute issues Neuro: likely anoxic encephalopathy with ?seizure activity--twitches No pupillary reflexes, no response to noxious stimuli. Poor prognosis. was on bedside EEG telemetry. started on phenytoin for seizure prophylaxis. DM:insulin gtt given critical illness Vascular: continued aspirin, plavix given history of subclav and coronary stents--not exactly sure of timing of stents, no evidence of bleeding at this time resp: intubated in setting of arrest, weaning limited primarily by mental status GI prophylaxis: protonix DVT prophylaxis:subcu heparin Lines: right subclav placed [7-2] at [Hospital1 34], right aline [7-2] at [Hospital1 34] Code:full as per wife Medications on Admission: 1. aspirin 325 2. plavix 75 3. subcu heparin 4. levophed mcg/min 5. metoprolol 25 [Hospital1 ] 6. insulin gtt 7. bicarb gtt 8. fosphenytoin Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Pulseless electrical activity arrest Discharge Condition: Death Discharge Instructions: None Followup Instructions: None Completed by:[2147-8-19]	[ "427.5", "585.9", "584.5", "276.2", "V49.76", "440.1", "414.01", "285.21", "250.00", "412", "443.9", "401.9", "428.0", "414.02" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]	7240, 7249	5084, 7016	377, 383	7329, 7336	3616, 5061	7389, 7424	2702, 2720		7211, 7217		7270, 7308		7042, 7188			7360, 7366									2735, 3597																								274, 339										411, 2295															2317, 2549	2565, 2686
25,317	187,324	12931	Discharge summary	report	Admission Date: [2133-1-29] Discharge Date: [2133-2-17] Date of Birth: [2059-1-24] Sex: M Service: CARDIOTHORACIC Allergies: Morphine Attending:[First Name3 (LF) 165] Chief Complaint: Chest pain. Major Surgical or Invasive Procedure: [2133-1-30] Cardiac Catherization [2133-2-4] Coronary Artery Bypass Graft (Left internal mammary artery -> Left anterior descending, Saphenous vein graft -> posterior descending, Radial artery -> Obtuse marginal 1 -> Obtuse marginal 2), Mitral Valve Repair (26mm [Company 1543] Band) History of Present Illness: 74 year old male who presented with chest pain and shortness of breath on exertion. Patient was well until 3-4 weeks ago when he noticed exertional dyspnea when climbing a flight of stairs or out shopping. This has progressed to where the patient now has substernal "chest pressure" or "heavyness" when walking [1-10] blocks or climbing 1 flight of stairs in his home. He also notes some SOB upon awakening in the mornings, but denies PND. He sleeps with 2 pillows at baseline, but reports that his breathing is improved when he's upright lately. He denies any symptoms of chest pain/pressure or SOB at rest. Past Medical History: Coronary Artery Disease Mitral Regurgitation Heart Failure (systolic) Paroxysmal Atrial Fibrillation Renal Insufficiency Peripheral Vascular disease Hypertension Chronic Anemia AAA s/p Endovascular stent [2129] Myocardial Infarction [2109] Gout Osteoathritis Venous ligation GI bleeding Social History: retired, worked in plastics factory, Married lives with spouse [Name (NI) 1139] - quit 25 years ago, 80 pack year history Denies ETOH Family History: Brother and mother deceased from [Last Name ] problem Physical Exam: Blood pressure was 170/100 mm Hg while seated. Pulse was 78 beats/min and irregular, respiratory rate was 19 breaths/min. Generally the patient was well developed, well nourished and well groomed. The patient was oriented to person, place and time. The patient's mood and affect were not inappropriate. . There was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa. neck was supple with JVP of 11 cm with postive hepatojugular reflex The carotid waveform was normal. There was no thyromegaly. The were no chest wall deformities, scoliosis or kyphosis. The patient has a prominent venous pattern in his subcutaneous tissues. The respirations were not labored and there were no use of accessory muscles. The lungs had soft end expiratory crackles bilaterally at both bases. Palpation of the heart revealed the PMI to be located in the 5th intercostal space, mid clavicular line. There were no thrills, lifts or palpable S3 or S4. The heart sounds revealed an irregular heart beat, S1 and the S2 were normal. There were no rubs, murmurs, clicks or gallops. The abdominal aorta was not enlarged by palpation. There was no hepatosplenomegaly or tenderness. The abdomen was obese, soft nontender and nondistended. His liver span was estimated to be 5cm by percussion. He did not have a palpable spleen. The extremities had no pallor, cyanosis, clubbing or edema. There were no abdominal, femoral or carotid bruits. skin revealed darkened skin on dorsum of both hands, with pale lower extremities which pt relates to sun eposure. no evidence of stasis dermatitis, ulcers, scars, or xanthomas. . Rectal Exam: Smooth symmetrically enlarged prostate with brown stool in rectal vault. Guaiac Negative. Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT not palpable Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP not palpable PT not palpable Pertinent Results: Labs from [Hospital3 ] notable for: Wbc 5, Hct 45.4, Plate 255 BUN 36, Cr 2.1 Alk phos 104, Albumin 4 Lipid panel: LDL 134, Trig 176, HDL 29 Pt 13.2/INR 1.1 . LABS ON ADMISSION: . 142 106 39 AGap=16 ------------< 120 4.4 24 2.1 . CK: 62 MB: Notdone Trop-T: <0.01 . Ca: 10.0 Mg: 2.3 P: 3.7 . ALT: 19 AP: 118 Tbili: 0.8 Alb: AST: 20 LDH: 248 . MCV 90 WBC 11.0 Hb 14.4, HCT 43.7, 239 . N:65.7 L:24.7 M:5.0 E:2.5 Bas:2.0 PT: 12.6 PTT: 26.4 INR: 1.1 [2133-1-30] Echocardiogram: EF 35-40%, the left atrium is mildly dilated. The right atrium is moderately dilated. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is moderately depressed with thinned and akinetic inferior/inferolateral. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2130-3-27], findings are similar. [2133-2-2] Chest X-ray: 1. Subpleural areas of reticular opacity with associated traction bronchiectasis, corresponding to the abnormalities seen on the recent chest radiograph. Findings likely reflect sequela of prior infectious etiology or chronic aspiration. 2. Panacinar emphysema with upper lobe predominance. 3. Extensive coronary artery calcifications. [2133-2-3] Bladder U/S: Arising from the left posterior bladder wall, there is a 1.7 x 1.2 x 2.1 cm soft tissue lesion. The lesion is solid, therefore this would not be consistent with an ureterocele and more concerning for a bladder mass or benign solid lesion. When compared to the prior CT of [2130-8-8], the greatest dimension has slightly increased in size (from 1.8 to 2.1 cm). Normal bilateral ureter jets are seen. No other bladder abnormalities are detected. 1.7 x 1.2 x 2.1 soft tissue lesion arising from the left posterior bladder wall adjacent to the orifice of the left ureter. Given slight interval growth compared to CT of [Month (only) 216] [2129] and solid appearance this may represent a benign or malignant solid lesion and further workup with cystoscopy is recommended. [2133-1-30] Cardiac Catheterization 1. Three vessel coronary artery disease. 2. Elevated filling pressures. 3. Depresed cardiac index. 4. Moderate pulmonary artery systolic hypertension. 5. Moderate systemic arterial systolic hypertension. Brief Hospital Course: Presented for evaluation of chest pain, started on heparin for atrial fibrillation and underwent cardiac catheterization [2133-1-30] which revealed three vessel coronary artery disease. Cardiac Surgery was consulted and he underwent preoperative workup. While on heparin he developed both hematuria and bright red blood per rectum. A bladder ultrasound revealed a mass and urology was consulted. Bladder irrigation was started and he was cleared by urology for cardiac surgery. GI was consulted, his hematocrit dropped by 2 points and he was cleared for surgery. Heparin and plavix were stopped in anticipation of surgery and given his bleeding. He went to the operating room on [2133-2-3] where coronary artery bypass grafting to four vessels was performed as well as a mitral valve repair using a 26mm [Company ] band. Of note, left radial artery, internal mammary and saphenous vein was used for bypass conduit. Please see operative report for further details. Postoperatively he was transferred to the cardiac surgery recovery unit for further monitoring. He required bladder irrigation for hematuria in the OR which was continued in the unit. Initially he required milrinone and pressors which were weaned off over 24 hours. On postoperative day one, he awoke neurologically intact and was extubated. Bladder irrigation was stopped and he remained without hematuria. On POD #2 he had atrial fibrillation which was treated with beta blockers and amiodarone. The renal service was consulted for an elevated creatinine which slowly trended back towards normal. As he remained in atrial fibrillation, heparin as a bridge to coumadin was started for anticoagulation. He continued to make slow progress and remained in the unit for pulmonary care and diuresis until postoperative day six. He was then transferred to the step down unit for further recovery. The physical therapy continued to work with him to help increase his strength and mobility. Mr. [Known lastname 39719] continued to make steady progress and was ready for discharge to rehab on POD 13. He will follow-up with the urology service for further management of his bladder mass. His coumadin will be managed by Dr. [Last Name (STitle) 24717] for an INR of 2.0-2.5 for atrial fibrillation. The vascular surgery service will follow-up with him in a couple of weeks for a revision of his infrarenal aortic stent. Lastly, Mr. [Known lastname 39719] will follow-up with Dr. [First Name (STitle) ] and his primary care physician as an outpatient. Medications on Admission: aspirin 325 daily plavix 75mg daily (started 1 day PTA) Ranitidine 150mg [Hospital1 ] Metoprolol 50mg [Hospital1 ] Isosorbide Dinitrate 20mg [Hospital1 ] Nitroglycerin 0.4mg tab PRN Ambien 5mg PRN Allopurinol 100mg qam Tetracycline 500mg daily for rosacea All/ADR's: Morphine- rash Discharge Medications: 1. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily) for 3 months: For radial artery graft . 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 7. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400 [Hospital1 ] x 2 days, then 400 daily x 1 week, then 200 mg daily ongoing. 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. 10. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: Does for goal INR of 2.0-2.5 for atrial fibrillation. . 11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 12. Atrovent HFA 17 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation four times a day as needed for shortness of breath or wheezing. 13. Flovent HFA 110 mcg/Actuation Aerosol Sig: One (1) puff Inhalation twice a day. Discharge Disposition: Extended Care Facility: [Location (un) 11292] Discharge Diagnosis: Coronary Artery Disease s/p CABG Mitral Regurgitation s/p MV repair Left trigone bladder mass Heart Failure (systolic) Paroxysmal Atrial Fibrillation Renal Insufficiency Peripheral Vascular disease Hypertension Chronic Anemia AAA s/p Endovascular stent [2129] Myocardial Infarction [2109] Gout Osteoathritis Venous ligation GI bleeding Discharge Condition: Good Discharge Instructions: 1) [Month (only) 116] shower, no baths or swimming 2) Monitor wounds for infection - redness, drainage, or increased pain. 3) Report any fever greater than 101 4) Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week 5) No creams, lotions, powders, or ointments to incisions 6) No driving for approximately one month 7) No lifting more than 10 pounds for 10 weeks 8) Coumadin for atrial fibrillation. Goal INR is 2.0-2.5. Dr. [Last Name (STitle) 24717] will follow as an outpatient. Please call to schedule appointment on discharge from rehab. [Telephone/Fax (1) 24721] 9) Take lasix for 1 week then stop. 10) Take amiodarone as instructed. 400 twice daily for s days, then 400 daily x 1 week, then 200 mg daily ongoing until instructed by Dr. [Last Name (STitle) 24717] 11) Please call with any questions or concerns Followup Instructions: Dr [Last Name (STitle) 261] follow up for bladder mass as outpatient - please call to schedule appointment ([Telephone/Fax (1) 39720]) Dr [First Name (STitle) ] in 4 weeks ([Telephone/Fax (1) 170]) please call for appointment Dr [First Name8 (NamePattern2) 122] [Last Name (NamePattern1) 24717] after discharge from Rehab ([Telephone/Fax (1) 24721]) - He will also be following your coumadin dosing. please call for appointment. Dr. [Last Name (STitle) 3407] [Telephone/Fax (1) 1241] His office will contact you to schedule surgery. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2133-2-17]	[ "428.20", "414.01", "584.9", "715.90", "274.9", "276.2", "411.1", "424.0", "412", "239.4", "440.20", "403.90", "427.31", "285.29", "578.9", "428.0", "599.7", "585.9" ]	icd9cm	[ [ [] ] ]	[ "35.33", "96.72", "36.13", "37.23", "36.15", "88.56", "39.61" ]	icd9pcs	[ [ [] ] ]	10614, 10666	6355, 8898	286, 584	11054, 11061	3685, 3853	11972, 12663	1716, 1775		9245, 10591		10687, 11033		8924, 9222			11085, 11949									1790, 3666																								235, 248										612, 1226									3867, 6332						1248, 1545	1561, 1700
28,220	143,144	31384	Discharge summary	report	Admission Date: [2118-6-15] Discharge Date: [2118-6-26] Date of Birth: [2042-10-27] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: Vfib Arrest Major Surgical or Invasive Procedure: PROCEDURES: 1. Redo coronary bypass grafting times one with reversed saphenous vein graft from the aorta to the first diagonal coronary artery. 2. Aortic valve replacement with a 27 mm [Company 1543] Mosaic aortic valve bioprosthesis. History of Present Illness: CCU ADMISSION NOTE . cc:[CC Contact Info 73948]. HPI: 75 year old man w/hx of AS, CABG x4 in [2110], recent PCI with stenting of RCA and POBA to 80% diagonal [1-/2118](Dr. [Last Name (STitle) 3302]presenting as transfer from outside hospital after VF arrest. The patient had been reporting increasing amounts of chest pain beginning 2 months after PCI, mostly at night, thought to be consistent with his known Reflux Disease. He had been frequently awaking at night with pain, elevating his arms, turning on his side, and taking both isosorbide dinitrate and nitroglycerine up to 4 days per week. These measures would relieve his pain. On the day of his arrest, however, he awoke in the morning with similar and severe pain ([9-21]). It did not abate throughout the day, despite taking 2.5 mg of isordil x5 and SL NTG x 4 before he arrived at OSH. During his work up, he had continuing chest pain, received ECG w/o ST changes, then SL nitroglycerine and then turned pale and lost consciousness. He was found to be in Vfib arrest, was shocked once with an AED, then received atropine x 1, lidocaine gtt. Now AAOX3, with sternal tenderness. No CP as before arrest. . He was transfered here for cardiac cath which showed no significant change from [2118-1-11], save for 95% restenosis of previously POBA'd 80% diag. Past Medical History: Hypertension Hyperlipidemia History of Left Bundle Branch Block CAD, s/p CABG x 4 in [2110] (LIMA-LAD, SVG-OM1, SVG-OM2, SVG-dRCA) CAD s/p PCI [1-/2118] with BMS Stenting to RCA and POBA to 80% Diag. Aortic Stenosis h/o Cholecystitis Hernia repair [2117-8-15] Prostate ca s/p hormone shots Reports "hole in stomach" that was going to be repaired by Dr. [Last Name (STitle) ] within the past year, but was held given risks from CAD Social History: Married with two grown children. He does not smoke. Heavy drinking x 10 yrs, stopped 4 yrs ago. Exercised regularly 4 days per week until 1 year ago when limited by pain. He owns a testing lab for aircraft components. Family History: non-contributory Physical Exam: VS: T 98.6 BP 160/64, HR 75, RR 15, O2 97% on RA Gen: elderly man in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Well hydrated. Neck: Supple with JVP of 7 cm. Thyroid non-enlarged. CV: Regular rhythm, S1, S2, III/VI systolic crescendo-decrescendo murmur heard throughout precordium with radiation to carotids as well as apex. Sounds lower-pitched at upper sternal borders, and higher pitched at apex. No gallop or rub. Chest: Old sternotomy scar. Resp were unlabored, no accessory muscle use. Crackles 1/3 up bilaterally. Abd: Large pannus, soft, NTND. No abdominal bruits. No organomegaly. Ext: 1+ LLE edema, trace R ankle edema. Pulses: Carotids pulsus parvus e tardus; Femoral 2+ BL; 1+ DP/PT BL Pertinent Results: [2118-6-26] 07:05AM BLOOD Hct-23.0* [2118-6-22] 06:13PM BLOOD PT-15.1* PTT-61.0* INR(PT)-1.3 [2118-6-25] 07:20AM BLOOD WBC-7.3 RBC-2.72* Hgb-8.5* Hct-24.1* MCV-89 MCH-31.3 MCHC-35.2* RDW-16.6* Plt Ct-115* [2118-6-25] 07:20AM BLOOD Glucose-123* UreaN-15 Creat-0.6 Na-139 K-3.7 Cl-102 HCO3-29 AnGap-12 [2118-6-24] 03:00AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.5 [2118-6-21] 03:38PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.012 URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2118-6-21] 3:38 pm URINE Source: CVS. URINE CULTURE (Final [2118-6-22]): NO GROWTH. [2118-6-25] 7:42 AM CHEST (PORTABLE AP) CHEST Cardiac size is enlarged. There is collapse consolidation in the left lower lobe with loss of the left hemidiaphragm. No evidence of a pneumothorax is seen. The right lung is clear. There is no failure. IMPRESSION: No pneumothorax, left lower lobe collapse consolidation Brief Hospital Course: [6-15] Vfib Arrest/Rhythm: Unclear what precipitant was. Cath was without an obvious clot or plaque rupture that would be responsible for his arrest. With his known valvular disease, it is possible that his preload was droppped enough with multiple nitroglycerine administration to cause global coronary ischemia and his Vfib. He was alert and oriented post-arrest. Admitted to the CCU Cardiology consult [6-16] - [6-22] awaitng plavix washout, Cardiac echo / carotid US / dental consult obtained for prep for surgery, IV hep for afib / thrombus PPX Coronary Artery Disease: diffuse three vessel disease without significant change on cath from previously. Does have 95% re-stenosis of previously angioplastied diagonal, but this is doubtful as cause of his arrest or ongoing anginal/gerd symptoms. His symptoms prior to arrest do sound very much like Reflux disease, but there is likely some angina as well. Screening CXR, carotid US and vein mapping completed. Plavix washout and CT surgery [6-22]. -Type and Cross 4U pre-op -Continue ASA, statin, lisinopril and metoprolol [6-22] PROCEDURES: 1. Redo coronary bypass grafting times one with reversed saphenous vein graft from the aorta to the first diagonal coronary artery. 2. Aortic valve replacement with a 27 mm [Company 1543] Mosaic aortic valve bioprosthesis. Extubated without complicaton [6-23] pt HCT 21 / transfused 2 units PRBC's epi drip for blood pressure support asa, plavix, BB, statin started peri op vanco insulin drip diuresis post operative adat [6-24] epi weaned off BB increased / hydralazine DC'd anemia stable ct / aline / cordis [Hospital 1788] transfer to regular floor diuresis continued tolerating diet [6-25] foley DC'd / urinating epicardial wires dc's pt consult [6-26] stable for dc Medications on Admission: Norvasc 2.5', Aspirin 325', Metoprolol 200', HCTZ 12.5', ASA 81', Niacin 500'', Lisinopril 5', Zocor 20', Isosorbide 10', Calcium 600 + Vitamin D 400 Units 2 caps', Elegard - last shot in [10/2117], Plavix 75' Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:14 Tablet(s) Refills:0 3. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 7 days. Disp:14 Packet(s) Refills:0 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(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. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO BID (2 times a day). Disp:60 Capsule, Sustained Release(s) Refills:2 9. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 13. 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 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:30 Tablet(s) Refills:0 15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Disp:30 Suppository(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 2436] Home Care Discharge Diagnosis: 1. Recurrent coronary artery disease, status post recent non-Q-wave myocardial infarction; status post previous coronary artery bypass grafting with patent grafts. 2. Aortic stenosis. Discharge Condition: Good Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower daily, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon OR at least 4 weeks. Followup Instructions: Provider: [Name10 (NameIs) ],[Name11 (NameIs) 177] [Name Initial (NameIs) ]. [Telephone/Fax (1) 170] Follow-up appointment should be in 1 month Provider: [Name10 (NameIs) 73949],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 73950] Follow-up appointment should be in 2 weeks Provider: [Name10 (NameIs) 2085] [Name11 (NameIs) ] appointment should be in 2 weeks Completed by:[2118-6-26]	[ "427.5", "401.9", "530.81", "410.71", "272.4", "V45.82", "414.01", "424.1", "427.41" ]	icd9cm	[ [ [] ] ]	[ "35.21", "37.23", "88.72", "88.57", "36.11", "88.53", "39.61", "88.56" ]	icd9pcs	[ [ [] ] ]	8576, 8637	4573, 6478	333, 583	8872, 8879	3543, 4550	9218, 9673	2675, 2693		6743, 8553		8658, 8851		6504, 6720			8903, 9195									2708, 3524																								282, 295										611, 1950															1972, 2423	2439, 2659
8,431	188,771	23491	Discharge summary	report	Admission Date: [2145-10-12] Discharge Date: [2145-10-15] Date of Birth: [2071-10-8] Sex: F Service: MEDICINE Allergies: Penicillins / Morphine Sulfate Attending:[First Name3 (LF) 14820] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 74yo woman with h/o CAD s/p MI and CABG, MVR with porcine valve in [2141], chronic GI bleed [1-1] AVMs, recent tibial, fibular, and pelvic fractures, who presents from rehab with chest pain and dyspnea. Patient reports that 2 nights prior to admission, she had acute chest pain to the left of her sternum radiating to her arm and back. Pain felt like a pressure and was associated with dyspnea, nausea, and sweating. She also notes increased dyspnea that does not have a positional component over the last week. Patient received nitroglycerin and ASA without relief of her pain, and she was transferred to an OSH, where she ruled in for NSTEMI with peak TnI of 1.17. Echo done at OSH was significant for newly depressed EF (10-20% vs normal EF in [2145-7-31]). Heparin and integrilin gtt were started. Patient also had b/l LE ultrasound which was negative for DVT. . She is now transferred to [Hospital1 18] for cardiac cath. Of note, the patient woke at 4am today with 15/10 chest pain across her chest, relieved by fentanyl but not by nitroglycerin. Pain was reproducible on exam. She now c/o [2148-1-3] chest pain; she is not feeling SOB. Past Medical History: Dyslipidemia IMI in [2135] treated with thrombolytics CABG: SVG to Ramus in [2141], concurrent MVR with 25mm porcine valve Occult GI bleeding [1-1] upper and lower AVMs, for which she has required numerous transfusions, most recently 1 unit [Unit Number ] weeks ago and 2 units about 3 weeks ago GERD Diverticulosis s/p bilateral hip replacements with revision on the right recent fall with R tibia-fibula fractures recent pelvic fracture--3 weeks ago costochondritis pseudogout fibromyalgia anxiety depression . PCP: [Name10 (NameIs) 60169] [Name11 (NameIs) ] Cardiologist: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] . ALLERGIES: PCN-->rash and pruritus and hands swell morphine -->pruritus, reports she tolerates morphine when given benadryl Social History: Currently in rehab/short term [Hospital1 1501] at [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 731] in [Location (un) 47]; otherwise, lives with husband in [Name (NI) 47]. Quit smoking 25 years ago (+tob x 15-20 years). No etoh, or illicit drug use. Family History: +Mother w/ MI at 54yo (also a diabetic) Maternal uncle with MI at 42yo 2 half-sisters with DM Physical Exam: VS: 98.2 97.0 88/50 (SBP 88-125), 61 16 100% 3L GENERAL: No apparent distress, alert & oriented x 3, appropriate HEENT: EOMI, pale conjunctiva. Oral mucosa moist and clear. NECK: supple. No carotid bruits. No thyromegaly or nodule. CHEST: scar from prior sternotomy w/ minor scabbing, no scoliosis or kyphosis. Lungs clear b/l CVS: RRR, nl S1/S2. No M/R/G. ABD: +BS. soft, NT/ND. The abdominal aorta was not palpated. No hepatosplenomegaly. EXT: Warm, without edema. NEURO: alert, oriented, answers questions appropriately . Pulses: Right: Carotid 2+ Femoral 2+ DP 2+ Left: Carotid 2+ Femoral 2+ DP 2+ Pertinent Results: [2145-10-12] 09:44PM BLOOD WBC-5.2 RBC-4.16* Hgb-12.4 Hct-37.1 MCV-89 MCH-29.9 MCHC-33.6 RDW-13.2 Plt Ct-259 [2145-10-15] 07:50AM BLOOD WBC-6.3 RBC-3.98* Hgb-11.9* Hct-34.8* MCV-88 MCH-29.8 MCHC-34.1 RDW-13.0 Plt Ct-205 [2145-10-15] 07:50AM BLOOD PT-13.1 PTT-31.0 INR(PT)-1.1 [2145-10-12] 09:44PM BLOOD Glucose-111* UreaN-23* Creat-1.3* Na-139 K-3.6 Cl-100 HCO3-30 AnGap-13 [2145-10-13] 04:45AM BLOOD Glucose-202* UreaN-23* Creat-1.5* Na-137 K-3.8 Cl-96 HCO3-30 AnGap-15 [2145-10-13] 07:44PM BLOOD Glucose-125* UreaN-19 Creat-1.2* Na-140 K-3.7 Cl-102 HCO3-29 AnGap-13 [2145-10-15] 07:50AM BLOOD Glucose-98 UreaN-19 Creat-1.1 Na-139 K-4.6 Cl-101 HCO3-29 AnGap-14 [2145-10-12] 09:44PM BLOOD ALT-32 AST-39 LD(LDH)-223 CK(CPK)-48 AlkPhos-72 TotBili-0.5 [2145-10-15] 07:50AM BLOOD ALT-74* AST-76* LD(LDH)-276* AlkPhos-82 Amylase-51 TotBili-0.5 [2145-10-12] 09:44PM BLOOD CK-MB-NotDone cTropnT-0.17* proBNP-[Numeric Identifier ]* [2145-10-13] 04:45AM BLOOD CK-MB-NotDone cTropnT-0.24* [2145-10-14] 03:34AM BLOOD CK-MB-NotDone cTropnT-0.18* [2145-10-12] 09:44PM BLOOD ALT-32 AST-39 LD(LDH)-223 CK(CPK)-48 AlkPhos-72 TotBili-0.5 [2145-10-13] 04:45AM BLOOD CK(CPK)-93 [2145-10-12] 09:44PM BLOOD Triglyc-99 HDL-54 CHOL/HD-2.5 LDLcalc-61 . EKG: NSR with normal axis, inf Q waves and TWI in inferior and lateral leads, new compared to [2141] (T waves flat at that time). . 2D-ECHOCARDIOGRAM: [2145-8-16] (report from [Hospital1 ]): "LVH, normal LV fxn, mild to mod pulmonic insufficiency" [2145-10-12] (report from [Hospital1 ]): "limited 2d-echocardiogram: dense septal and apical akinesis with EF 10-20%, profoundly changed from prior." . ETT: p-[First Name9 (NamePattern2) 1608] [2145-8-20] (report from [Hospital1 ]): "no significant perfusion defects" . CARDIAC CATH: ([Hospital1 ] in [2141]): 40% occluded RCA, 50% LMCA . LABORATORY DATA: from [Hospital1 ]: CPK 28-->43-->44 TnI 0.04-->1.17-->1.10 . CXR [10-12]: Cardiac size is top normal. The patient is post median sternotomy CABG and MVR. The lungs are grossly clear. There is no evidence of CHF or pneumonia. There are no sizeable pleural effusions. . CT abdomen/pelvis without contrast [2145-10-13]: 1. No evidence of intra-abdominal or retroperitoneal hematoma to account for patient's hematocrit drop. Hematoma in the left iliopsoas region likely relates to subacute pelvic fractures. 2. Left lobe hepatic cyst. 3. Small bilateral pleural effusions and atelectasis. . TTE [2145-10-14]: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. There is mild global left ventricular hypokinesis (LVEF = 45-50%). The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion IMPRESSION: Mild global left ventricular systolic dysfunction. Normally-functioning mitral valve bioprosthesis. . Cardiac Cath [2145-10-13] (prelim report): No flow-limiting lesions; patent graft Brief Hospital Course: 74yo woman with CAD s/p CABG, chronic GI bleed from AVMs, and recent pelvic fracture who presents with chest pain. . # Chest pain: In setting of small troponin leak and new LV dysfunction, patient was initially suspected of having CAD, put on heparin gtt, and brought to cath lab. She did not have any flow-limiting lesions and her graft was patent (final report pending). Alternative explanations for her presentation were considered, including viral myocarditis or Takotsubo syndrome. Repeat echocardiogram done at [Hospital1 18], however, showed only mild global hypokinesis with EF 45%, which did not suggest Takutsobu syndrome. Moreover, her CKs were never elevated. The patient has multiple other potential causes of chest pain, including costochondritis, fibromyalgia, and anxiety. PE was deemed unlikely given that patient has been on lovenox and her RV pressures were not significantly elevated at cath. Some of her pain is reproducible on exam, suggesting a musculoskeletal component. She was put on IV morphine with good control of her pain and no symptomatic itch (although morphine is listed as an allergy for her). She was transitioned to MS contin with oxycodone for breakthrough pain. . # Acute systolic heart failure: Patient had no clinical evidence of heart failure by history or exam. She was put on lisinopril and metoprolol for medical management. Her doses of metoprolol and lisinopril should be increased as tolerated by her blood pressure. Also, her creatinine and K+ should be checked in one week given recent initiation of ACE I. . # Hypotension: Patient had asymptomatic hypotension with SBP in 70s after her cardiac catheterization. She was felt to be oversedated after receiving IV fentanyl on top of her fentanyl patch. Her fentanyl patch was stopped and she was monitored overnight in the unit. Her blood pressures improved and remained stable thereafter. . # CAD s/p CABG: Patient had no flow-limiting lesions on cath. Her troponins peaked at 0.24 and her CK was never elevated. She was medically treated for CAD with ASA, beta blocker, and simvastatin. Of note, her pain responded to opiates but not to nitrates. . # QT prolongation: Noted on EKG. QT prolonging agents should be avoided. . # multiple fractures, chronic pain/fibromyalgia: Pain control as discussed above. Bowel regimen while on narcotics. Continued gabapentin and lidoderm patch to right back. DVT prophylaxis with lovenox continued. Patient should follow-up with her orthopedist to determine her weight-bearing status and continue to have care with physical therapy. . # h/o GI bleeding from AVMs and GERD; Hematocrit drop: After cardiac cath, Hct was drawn and dropped from 37->22. CT abdomen/pelvis did not show evidence of retroperitoneal bleed, and recheck of Hct was 33. The hematocrit of 22 was felt to be lab error. She did receive a transfusion of 1 unit of pRBCs, and her Hct remained stable at 33-34 throughout the rest of admission. Protonix [Hospital1 ], sucralfate, and ranitidine were continued. . # Mild transaminase elevation: Patient ALT and AST increased from 30s to 70s while on zocor. Her simvastatin was stopped and her ALT and AST should be rechecked in one week. Her cardiologist, Dr. [First Name (STitle) ], should advise the patient as to whether to continue with simvastatin. . # Gout: Colchicine. . # Depression, Anxiety: Lorazepam continued. Patient's trazodone had been held at rehab. It was held during admission as well because of her hypotension. It can be restarted at 150mg QHS and titrated up as necessary by her PCP. Medications on Admission: vicodin 5/500 1-2 tabs Q6 prn compazine 5mg po Q6 prn tylenol prn bisacodyl PR prn MVI daily simethicone 80mg tid baclofen 10mg tid gabapentin 300mg tid lidoderm to R hip lovenox 40mg subcut. daily NTG patch 0.2mg/hour on 12 hrs/off 12 hours ranitidine 150mg QHS zocor 40mg QHS sucralfate 1gm tid with meals fentanyl 50mcg/hr patch Q3D Aciphex 20mg [Hospital1 ] ASA 81mg daily colace [Hospital1 ] prn Folate 1mg QHS Colchicine 0.6mg po BID Lorazepam 1mg HS PRN anxiety Trazodone 600mg QHS [Doctor First Name ] Vitamin D Vitamin B shot monthly Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Aciphex 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for indigestion. 7. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a day. 16. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for anxiety. 17. Enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg Subcutaneous DAILY (Daily): Until instructed to stop by orthopedics. 18. Vitamin D Oral 19. Vitamin B-12 Injection 20. [Doctor First Name ] Oral 21. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 22. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 23. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 24. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 25. Trazodone 150 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Extended Care Facility: [Hospital 25499] [Hospital 731] - [Location (un) 47] Discharge Diagnosis: Primary Diagnosis: Chest pain Secondary Diagnoses: Coronary Artery Disease s/p CABG; Chronic GI bleed from AVMs; recent pelvic fracture; Depression; Costochondritis Discharge Condition: Patient had chest pain felt to be musculoskeletal, responding to oral medications. Her blood pressure was stable and repeat echocardiogram demonstrated only mildly depressed ejection fraction. Vitals were stable, no fevers. Discharge Instructions: You were admitted with chest pain. You had a cardiac catheterization that showed that you have no blockages of the artieries to your heart muscle. 1. Please take all medications as prescribed. 2. Please attend all follow-up appointments listed below. 3. Please call your doctor or return to the hospital if you develop chest pain, shortness of breath, fevers, palpitations, or any other concerning symptom. Medication changes: - Stop your zocor (simvastatin) because your liver enzymes were a little elevated. Your liver tests will be rechecked in a week and your doctors [Name5 (PTitle) ] let [Name5 (PTitle) ] know whether you should restart zocor. - Stop your fentanyl patch because your blood pressure was very low when you were on fentanyl. Instead, you are on morphine and oxycodone pills for pain control. - Stop your nitroglycerin patch for now. You did not appear to benefit from the nitro patch, so we stopped it. If you find you have chest pain that responds to the nitroglycerin patch, you can restart it. - We started lisinopril and metoprolol, which are medications that will be good for your heart and blood pressure. Lisinopril is once a day; metoprolol is twice a day. - We also started senna to keep your bowels moving while you are on narcotics. - We are restarting your trazodone at a lower dose. Your primary doctor may need to adjust this as needed in the future. Followup Instructions: 1. Please arrange to see your primary care doctor in the next month. His number is [Telephone/Fax (1) 60170], Dr. [Doctor Last Name 60171] [Name (STitle) ] 2. Please follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], your cardiologist, in the next 3-4 weeks. 3. Please see your orthopedics doctor to continue care for your hip. Completed by:[2145-10-15]	[ "530.81", "V43.64", "425.4", "275.49", "712.38", "300.4", "786.59", "458.8", "V43.3", "414.00", "569.85", "V58.66", "733.6", "V45.81", "729.1", "790.4", "272.4", "562.10", "412", "416.8" ]	icd9cm	[ [ [] ] ]	[ "88.56", "37.22" ]	icd9pcs	[ [ [] ] ]	13150, 13241	6891, 10487	305, 331	13452, 13680	3439, 6868	15129, 15536	2695, 2790		11092, 13127		13262, 13262		10513, 11069			13704, 14112									2805, 3420			13315, 13431																		14132, 15106			255, 267										359, 1530								13282, 13293							1552, 2345	2361, 2679
28,824	139,589	43624+58641	Discharge summary	report+addendum	Admission Date: [2133-3-15] Discharge Date: [2133-4-5] Service: CARDIOTHORACIC Allergies: Codeine / Cortisone / Lipitor / Lisinopril Attending:[First Name3 (LF) 922] Chief Complaint: SOB/edema Major Surgical or Invasive Procedure: s/p CABGx3(LIMA->LAD, SVG->[Last Name (LF) ], [First Name3 (LF) ])/MV repair(26mm annuloplasty band)/MAZE [3-23] History of Present Illness: 84 Y F w/ hx afib on coumadin/amio, diastolic heart failure, admitted [2133-3-15] with flash pulmonary edema in setting of hypertensive emergency. Pt felt very itchy, with headache, rapid heart rate and SOB; thought related to not taking hydroxyurea, as that has helped with her itchines in the past but became progressively more short of breath and decided to call EMS. Also states over the past few months has been having DOE releived by rest. Per Dr. [Name (NI) 93802] note she had a recent stress with possible RCA stenosis and moderate AS. Pt denies any dietary indiscretion, any medication changes other than beging started on Levothyroxine and aspirin 81mg recently. She denies any weight changes or increased lower extremity edema. Past Medical History: - Diastolic and systolic CHF EF 45% 10/07 TTE, diastolic CHF 65% on pMIBI [10-16] - AFIB on coumadin - Mild AS - TIA [4-12] - Polycythemia [Doctor First Name ] - phlebotomized in past, maintained on hydroxyurea - HTN - Hypercholesterolemia - Cataracts - LBBB, first degree AV block - Asthma - diagnosed in her 70s - Peripheral neuropathy Social History: Lives alone in [Location (un) ], independent ADLs, previously worked as a bookkeeper. No ETOH, smoked rarely as a teenager, no illicit drugs. Daughter who she would like to be her HCP although not formally established. Her daughter lives in [Location (un) 538] and helps her out as needed (Klickstein [Telephone/Fax (1) 93800]). Family History: Father died 61 of MI, mother died in 70's of an MI, brother died age 43 of MI, no other hx of CAD, CVA, DMII Physical Exam: (on admission) Wt: 74.5 kg admission weigh VS: T 97 HR 60 BP 105/64 RR 15 SaO2 95%RA GEN: respiratory distress, speaking in short sentences HEENT: PERRLA, MM slightly dry, oropharnx clear Neck: JVP difficult to assess, no LAD Resp: decreased breath sounds bilaterally, but no crackles CV: RRR, S1/S2 present, [2-12] harsh crescendo murmur radiation to carotids as well as II/VI holosystolic murmur over apex Abd: soft, NT/ND, +BS, no HSM, guaiac negative In MICU Ext: trace edema, varicose veins B/L, 1+ DP/PT BL Neuro: moving all extremities, answering questions appropriately Skin: Varicosities but no rash Pertinent Results: On admission: [2133-3-15] 05:24PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.007 [2133-3-15] 05:24PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2133-3-15] 05:24PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 [2133-3-15] 04:26PM GLUCOSE-109* UREA N-26* CREAT-1.4* SODIUM-138 POTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15 [2133-3-15] 04:26PM CK(CPK)-60 [2133-3-15] 04:26PM CK-MB-NotDone cTropnT-0.05* [2133-3-15] 04:26PM CALCIUM-8.8 PHOSPHATE-4.3 MAGNESIUM-2.1 [2133-3-15] 01:24PM TYPE-ART PO2-128* PCO2-38 PH-7.43 TOTAL CO2-26 BASE XS-1 [2133-3-15] 01:24PM K+-4.1 [2133-3-15] 10:55AM PH-7.21* COMMENTS-GREEN TOP [2133-3-15] 10:55AM GLUCOSE-228* LACTATE-1.9 NA+-136 K+-4.2 CL--99* TCO2-23 [2133-3-15] 10:55AM freeCa-1.13 [2133-3-15] 10:37AM GLUCOSE-254* UREA N-26* CREAT-1.4* SODIUM-137 POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-25 ANION GAP-15 [2133-3-15] 10:37AM TSH-7.4* [2133-3-15] 09:20AM CK-MB-4 proBNP-871* [2133-3-15] 09:20AM CK(CPK)-116 [2133-3-15] 09:20AM cTropnT-<0.01 . Echo ([2133-3-16]): The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with mild aortic valve stenosis (valve area 1.4cm2) The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . CXR ([2133-3-16]): As compared to the previous examination, there is clear regression of the marked interstitial pneumonia. However, there are still signs of interstitial fluid overload and a clear cardiomegaly. No evidence of pleural effusions. . EKG ([2133-3-15]): rate 60s, no ST-T wave changes, LBBB (not new), 1st degree AVB [2133-3-31] 01:20AM BLOOD WBC-16.6* RBC-3.16* Hgb-8.5* Hct-26.2* MCV-83 MCH-26.9* MCHC-32.4 RDW-22.5* Plt Ct-760* [2133-3-31] 01:20AM BLOOD PT-18.7* PTT-83.6* INR(PT)-1.7* [2133-3-30] 08:00AM BLOOD PT-15.7* PTT-49.7* INR(PT)-1.4* [2133-3-27] 02:51AM BLOOD PT-14.4* PTT-34.3 INR(PT)-1.3* [2133-3-23] 08:16PM BLOOD PT-15.3* PTT-58.7* INR(PT)-1.4* [2133-3-22] 07:55AM BLOOD PT-14.4* PTT-88.6* INR(PT)-1.3* [2133-3-30] 08:00AM BLOOD Glucose-113* UreaN-20 Creat-1.0 Na-136 K-4.1 Cl-102 HCO3-26 AnGap-12 [2133-3-22] 07:55AM BLOOD ALT-24 AST-30 LD(LDH)-317* CK(CPK)-46 AlkPhos-70 TotBili-0.7 RADIOLOGY Preliminary Report CHEST (PA & LAT) [2133-3-31] 10:04 AM CHEST (PA & LAT) Reason: ? effusion eval lead placement ppm [Hospital 93] MEDICAL CONDITION: 84 year old woman with s/p cabg REASON FOR THIS EXAMINATION: ? effusion eval lead placement ppm INDICATION: 84-year-old female status post CABG. Evaluate for effusion and lead placement. COMPARISON: [2133-3-28]. PA AND LATERAL VIEWS OF THE CHEST: A dual-lead cardiac pacer overlies the left hemithorax in a similar orientation with leads intact terminating in the right atrium and right ventricle. Median sternotomy wires are noted, unchanged in configuration. The patient is status post mitral valve annuloplasty. The cardiomediastinal silhouette is stable. There is slight increase in size of the bilateral moderate pleural effusions left greater than right. There is linear atelectasis in the left base. DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 10270] [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname 10900] [Hospital1 18] [Numeric Identifier 93803]Portable TTE (Complete) Done [2133-3-26] at 5:36:58 PM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) 177] [Hospital Unit Name 927] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2048-6-27] Age (years): 84 F Hgt (in): 63 BP (mm Hg): 84/53 Wgt (lb): 180 HR (bpm): 88 BSA (m2): 1.85 m2 Indication: H/O cardiac surgery. Left ventricular function. ICD-9 Codes: 414.8, 424.0 Test Information Date/Time: [2133-3-26] at 17:36 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 171], MD Test Type: Portable TTE (Complete) Son[Name (NI) 930]: [First Name8 (NamePattern2) 4134] [Last Name (NamePattern1) 4135], RDCS Doppler: Full Doppler and color Doppler Test Location: West SICU/CTIC/VICU Contrast: None Tech Quality: Suboptimal Tape #: 2008W032-0:40 Machine: Vivid [6-15] Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: >= 55% >= 55% Aorta - Sinus Level: 3.0 cm <= 3.6 cm Aorta - Ascending: 3.8 cm <= 3.4 cm Aorta - Arch: 3.0 cm <= 3.0 cm Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec Mitral Valve - Mean Gradient: 2 mm Hg Mitral Valve - E Wave: 1.3 m/sec Mitral Valve - E Wave deceleration time: 315 ms 140-250 ms TR Gradient (+ RA = PASP): 30 mm Hg <= 25 mm Hg Findings This study was compared to the prior study of [2133-3-16]. LEFT ATRIUM: Dilated LA. LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic function. Abnormal diastolic septal motion/position consistent with RV volume overload. AORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. Normal aortic arch diameter. AORTIC VALVE: Moderately thickened aortic valve leaflets. Significant AS is present (not quantified) No AR. MITRAL VALVE: Mitral valve annuloplasty ring. No MS. Trivial MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.] TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Borderline PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Mild PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Conclusions The left atrium is dilated. 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 is normal. with normal free wall contractility. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. Significant aortic stenosis is present (not quantified). No aortic regurgitation is seen. A mitral valve annuloplasty ring is present. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Grossly-preserved biventricular systolic function. Normally-functioning mitral annuloplasty ring. Compared with the prior study (images reviewed) of [2133-3-16], the regurgitant native mitral valve has been treated with an annuloplasty. Magnitude of aortic stenosis is likely similar, but was not quantified as well on the current study. The other findings are similar. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 171], MD, Interpreting physician [Last Name (NamePattern4) ] [2133-3-26] 18 Brief Hospital Course: In ED, Vitals T 96.0, H 86, BP 154/108, RR 34, O2 Sat 84 nrb. CXR showed new pulmonary edema. Pt was initially given 80iv of Lasix and 3 SLN en route to the [Hospital1 18]. She was then started on a Lasix gtt and also on a Nitro gtt for persistent hypertension with pressures in the 200 which subsequent pressures in the 120 range. ASA 325mg was given. An EKG showed lateral STD in the setting of hypertensive emergency. Levofloxacin and Azithromycin were given for possible CAP but d/c'd in MICU. She was started on CPAP at 12/8 initially and then titrated to [4-13], then in rapid sequence to NC and came off supplemental oxygen this pm with diuresis of about 2L on a lasix gtt. She has remained afebrile and without focal signs of infection although yesterday pm had a rise in WBC to 16 Labs on presentation also notable for an INR of 4 on presentation, coumadin was held. unclear what caused acute exacerbation (ischemia vs. hypertensive crisis). Pt had negative enzymes, and no EKG changes but transferred to [Hospital Ward Name 121] 3 for possible cath given recent stress with possible RCA lesion as culprit and no other clear source of acute HF. Pt was kept there for 2 days while waiting for INR to drift down and giving vit K for this so she could proceed to cardiac catheterization (She has history of Afib on coumadin) She was found to have 3VD on cath on [2133-3-19] (70% LAD, 90% LCx, 60% RCA) --> therefore the plan was for CABG the following monday with possble mitral valve replacement given significant MR. Although echo with EF>55%, RHC showed average wedge pressures about 30. Her aorta pressures were elevated to 180's at the time of cath and she developed flash pulmonary edema and SOB. She was diuresed in the cath lab with IV lasix 40mg + 60mg and she put out 2L of urine. Her respiratory status improved and she was transferred to the CCU for further care. In the CCU she was diuresed further improving and coming off supplemental O2. They also restarted losartan. She returned to [Hospital1 1516] on [3-20]. She was continued on ASA, no beta blocker since borderline bradycardic, no statin since LDL 76 in [10/2132] off statins and no acute MI. Workup for CABG was completed wiht carotid u/s without stenosis, vein mapping performed and lesser saph identified, LFTs WNL, albumin WNL, HbA1c WNL, Dental constult ok. On [3-21] pt became dehydrated and orthostatic, feeling lightheaded and with a vagal response when standing up. Therefore losartan was again stopped, but lasix continued. On [3-22] pt went to OR and underwent CABG x3/Mitral Valve repair/MAZE. She was transferred to the ICU in stable condition. POD#1 she was extubated without incident. Vancomycin was administered 48 hours perioperatively for her preoperative admission. Postoperatively her rhythm was asystolic recovering to junctional then slow atrial fibrillation, for which she was unsuccessfully cardioverted. Electrophysiology was consulted and on [2133-3-27] a PPM was placed.She was anticoagulated with Coumadin and Heparin for underlying AFib. [2133-3-31] Ciprofloxacin x 5 days was started for an asymptomatic UTI. Ready for discharge to rehab on POD # 9. Medications on Admission: Warfarin 1 mg PO daily alternating with 2mg Amiodarone 100 mg PO DAILY Valsartan 40 mg PO DAILY Furosemide 60 mg once a day Ferrous Sulfate 325 mg Colace 100 mg PO twice a day Senna 8.6 mg twice a day as needed Aspirin 81mg Daily Levothyroxine 25mcg Qdaily Hydrozyurea 500mg Cap Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks: then reassess need for diuresis. (preop dose 60 mg po daily). 11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily): while on lasix. 12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. 13. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for 1 days: check INR [2133-4-1]. 14. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: s/p CABG x3/MV repair (26 mm annuloplasty)/MAZE/hypothyroidism, asthma, CHF, AF, TIA, polycythemia [Doctor First Name ], HTN, ^chol., peripheral neuropathy, cataracts, s/p bil. vein ligation, s/p bil. rotator cuff injuries Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Dr [Last Name (STitle) 914] in 4 weeks ([Telephone/Fax (1) 170]) please call for appointment Dr [Last Name (STitle) 1270] in 1 week ([2133]) please call for appointment Wound check appointment [Hospital Ward Name 121] 2 as instructed by nurse ([Telephone/Fax (1) 3071]) Already scheduled appointments: Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2133-4-3] 9:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 9052], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2133-4-17] 10:30 Provider: [First Name8 (NamePattern2) 161] [Name11 (NameIs) 162] [Name8 (MD) 163], MD Phone:[Telephone/Fax (1) 921] Date/Time:[2133-4-20] 3:30 Completed by:[2133-3-31] Name: [Known lastname ],[Known firstname 6532] Unit No: [Numeric Identifier 14817] Admission Date: [2133-3-15] Discharge Date: [2133-4-5] Date of Birth: [2048-6-27] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Cortisone / Lipitor / Lisinopril Attending:[First Name3 (LF) 1543] Addendum: Pt. not discharged as planned on [3-31] due to SOB and supratherapeutic INR. Coumadin held. Target INR is 2.0-2.5. Continued to monitor INR with plan to resume when INR < 2.5 at rehab. Her diuresis was increased and her shortness of breath resolved. On chest xray there is a left pleural effusion that is small and continues to resolve with diuresis. Her permanent pacemaker was interrogated [4-4], in SR with 1 degree AVB and intermittent Atrial fibrillation. She was discharged to rehab on POD 13. Major Surgical or Invasive Procedure: s/p CABGx3(LIMA->LAD, SVG->[Last Name (LF) 1476], [First Name3 (LF) ])/MV repair(26mm annuloplasty band)/MAZE [3-23] Permanent Pacemaker placement [3-27] Elective cardioversion [3-27] Pertinent Results: [2133-4-4] 07:10AM BLOOD WBC-10.9 RBC-3.00 Hgb-8.1* Hct-25.4* MCV-85 MCH-26.9* MCHC-31.8 RDW-21.2* Plt Ct-673* [2133-4-5] 07:35AM BLOOD PT-38.2* INR(PT)-4.1* [2133-4-4] 07:17PM BLOOD PT-40.5* INR(PT)-4.4* [2133-4-4] 07:10AM BLOOD PT-41.2* INR(PT)-4.5* [2133-4-3] 05:30AM BLOOD PT-37.5* INR(PT)-4.0* [2133-4-2] 05:40AM BLOOD PT-41.0* INR(PT)-4.5* [2133-4-4] 07:10AM BLOOD Glucose-86 UreaN-17 Creat-1.4* Na-138 K-4.2 Cl-99 HCO3-30 AnGap-13 [2133-3-31] 7:21 am URINE Source: CVS. FINAL REPORT [2133-4-4] URINE CULTURE (Final [2133-4-4]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. SECOND MORPHOLOGY. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| ESCHERICHIA COLI \| \| AMPICILLIN------------ <=2 S <=2 S AMPICILLIN/SULBACTAM-- <=2 S <=2 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CEFUROXIME------------ 4 S 4 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- <=16 S <=16 S PIPERACILLIN---------- <=4 S <=4 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S 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. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 9. Coumadin please check daily INR and hold coumadin until INR 2.5 or less, then restart at 0.5mg daily with goal INR 2.0-2.5 for atrial fibrillation s/p maze 10. Amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day. 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day: please give 40mg twice a day for 7 days then decrease to 40mg daily. 12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 6 days. Discharge Disposition: Extended Care Facility: [Hospital3 901] - [Location (un) 382] Discharge Diagnosis: Coronary artery disease s/p CABG Mitral regurgitation s/p MV repair Atrial Fibrillation s/p MAZE Post op complete heart block s/p PPM PMH hypothyroidism Chronic systolic and Diasystolic heart failure Asthma Polycythemia [Doctor First Name 840] Hypertension Elevated cholesterol Peripheral neuropathy Cataracts Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Keep left elbow at shoulder level or below due to pacemaker 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) 1477] Please remove staples from posterior calfs on [2133-4-13] (3 weeks from surgery, please call if questions [Telephone/Fax (1) 1477]) Please check INR daily until 2.5 then restart coumadin at 0.5mg daily for goal INR 2.0-2.5 for atrial fibrillation s/p MAZE Followup Instructions: Dr [Last Name (STitle) ] in 4 weeks ([Telephone/Fax (1) 1477]) please call for appointment Dr [Last Name (STitle) 934] after discharge from rehab ([0-0-]) please call for appointment Device clinic in 3 months for pacer interrogation [Telephone/Fax (1) 1728] - please call to schedule Already scheduled appointments: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 14818], MD Phone:[Telephone/Fax (1) 1578] Date/Time:[2133-4-17] 10:30 Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 14819] Date/Time:[2133-4-20] 3:30 [First Name11 (Name Pattern1) 33] [Last Name (NamePattern4) 1544] MD [MD Number(2) 1545] Completed by:[2133-4-5]	[ "244.9", "287.5", "403.90", "493.90", "041.4", "V45.89", "366.9", "426.3", "426.0", "585.9", "599.0", "285.9", "E934.2", "272.0", "411.1", "427.31", "276.51", "790.92", "784.0", "V70.7", "424.0", "238.4", "458.29", "428.43", "428.0", "356.9", "424.1", "414.01" ]	icd9cm	[ [ [] ] ]	[ "36.12", "88.56", "39.61", "37.72", "39.64", "37.23", "89.45", "36.15", "37.83", "93.90", "35.12", "99.62", "37.33" ]	icd9pcs	[ [ [] ] ]	21037, 21109	10432, 13643	17855, 18061	21468, 21475	18080, 19778	22312, 23120	1917, 2029		19801, 21014	5607, 5639	21130, 21447		13669, 13949			21499, 22289									2044, 2667																								215, 226	5668, 10409									418, 1167									2700, 5570						1189, 1541	1557, 1901
69,791	109,706	49424	Discharge summary	report	Admission Date: [2132-11-7] Discharge Date: [2132-11-12] Date of Birth: [2061-12-9] Sex: M Service: MEDICINE Allergies: Codeine / Morphine Attending:[First Name3 (LF) 1943] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 70-year old gentleman with a history of diabetes, chronic kidney disease (baseline Cr 1.4) and diastolic CHF (EF LVEF>55) originally presenting from rehab facility on [11-7] for one day of hypotension 3 days after slipping and falling. Per report had been getting twice his usual dose of valsartan for unclear reasons. No chest pain, not SOB, but sweaty and mildly nauseated. Review of systems on admission was notable for malaise since his admission for chest pain at the start of [Month (only) 359]. He feels generally weak and apathetic, which is unusual for him. He has also had a non-productive cough for several weeks, for which he was started on azithromycin five days ago. He has recently been constipated. He denies recent fevers, chills, difficulty urinating or headaches. In the emergency department his VS were T 98, BP 94/48 improving to 134/99, HR 60, RR 18 and 100% on RA. He was found to have a new leukocytosis and crackles on lung exam and was given vanc, zosyn and flagyl for a hospital-acquired pneumonia. A right IJ was placed and he was given 3.5L of normal saline with improvement of BPs. He had elevated LFTs and an abdominal and pelvic CT scan was done, revealing a moderate pericardial effusion. He was admitted to the ICU for suspected sepsis. Past Medical History: Type 2 diabetes mellitus - diagnosed in [2121] CKD Stage III Anemia of CKD Hypertension Pontine CVA w/ residual left leg weakness Chronic bronchitis OSA COPD Obesity Hyperlipidemia Gout BPH H/o BCC S/p R shoulder replacement Social History: He is a retired teacher. He does not smoke or drink alcohol currently but used both remotely in [2083]. He admits to occasional marijuana. Prior to his worsening weakness and last hospitalization on [2131-10-10] he lived alone and did his own shopping/cooking and was independent with ADLs/IADLs. He was admitted now after having 2-3 weeks of rehab and he had been home for only 1 day. He has no children and has never been married but has siblings with whom he keeps in touch with regularly. Family History: Largely Noncontributory. The patient's mother had a type of sarcoma but he is uncertain of additional details. Physical Exam: VS: T 97.9 BP 102/64 HR 91 RR 22 O2sat 96 on room air BS 179 GEN: obese, comfortable, NAD HEENT: MMM Neck: JVP flat Cardiac: irregular irregular no R/G/M Chest: mild bibasilar crackles, otherwise CTAB Abdomen: soft, NT, ND, NABS Extremities: 1+ bilateral nonpitting edema Neuro: AXx3, CNII-XII grossly intact, EOMI Skin: diaphoretic Pertinent Results: Labs on Admission: [2132-11-7] 05:45PM BLOOD WBC-17.2* RBC-4.58* Hgb-13.7* Hct-40.8 MCV-89 MCH-30.0 MCHC-33.7 RDW-15.3 Plt Ct-301 [2132-11-7] 05:45PM BLOOD Neuts-88.4* Lymphs-6.0* Monos-4.6 Eos-0.7 Baso-0.4 [2132-11-7] 05:45PM BLOOD Glucose-175* UreaN-37* Creat-2.6# Na-134 K-3.8 Cl-90 HCO3-31 AnGap-17 [2132-11-7] 05:45PM BLOOD ALT-85* AST-64* CK(CPK)-53 AlkPhos-352* TotBili-0.9 [2132-11-7] 05:45PM BLOOD Calcium-8.9 Phos-3.6 Mg-2.3 [2132-11-7] 06:14PM BLOOD Glucose-174* Lactate-1.8 Na-134* K-3.1* Cl-87* calHCO3-33* [2132-11-7] 06:14PM BLOOD freeCa-1.02* Labs on Discharge: [2132-11-12] 04:50AM BLOOD WBC-13.9* RBC-4.02* Hgb-12.0* Hct-35.8* MCV-89 MCH-29.7 MCHC-33.4 RDW-15.6* Plt Ct-417 [2132-11-8] 03:32AM BLOOD Neuts-85.7* Lymphs-7.9* Monos-5.3 Eos-0.8 Baso-0.3 [2132-11-12] 04:50AM BLOOD Glucose-73 UreaN-34* Creat-1.6* Na-141 K-3.7 Cl-99 HCO3-30 AnGap-16 [2132-11-9] 01:38AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.7* Imaging: LIVER OR GALLBLADDER US [2132-11-7]: 1. Gallbladder sludge without secondary findings to suggest acute cholecystitis. 2. Diffusely echogenic liver consistent with fatty infiltration. Other forms of liver disease and more advanced liver diseases including significant hepatic fibrosis/cirrhosis cannot be excluded in this examination. Hypoechoic focus adjacent to the gallbladder fossa most likely represents focal sparing. CT PELVIS W/O CONTRAST Study Date of [2132-11-7]: 1. Moderate sized pericardial effusion, which is larger compared to [2132-10-22]. 2. Small bilateral pleural effusions, with opacification of the right lower [Last Name (LF) 3630], [First Name3 (LF) ] reflect atelectasis or consolidation. 3. Diverticulosis, without evidence of diverticulitis. 4. Single locule of air within the anterior subcutaneous fat in the lower abdomen. This may relate to subcutaneous injection. Clinical correlation suggested. CHEST (PORTABLE AP) Study Date of [2132-11-9]: Comparison is made with prior study [11-8]. Enlarged cardiomediastinal silhouette is stable. Patient has known pericardial effusion and mild cardiomegaly. Minimal bibasilar atelectases larger on the right side are unchanged. There is no pneumothorax or enlarging pleural effusions. Right IJ catheter remains in place. IMPRESSION: Stable appearance of the chest. Brief Hospital Course: Hypotension likely related to the recent increase in his valsartan. There was some concern that he might have an increasing pericardial effusion based on his chest CT. An echocardiogram showed no evidence of tamponade. Observed in MICU for 24 hours and pressures rising and stable. Transferred to floor for further monitoring. 1. Hypotension: Resolved with IVF. Given response to fluids most likely due to doubling of dose of [Last Name (un) ] and possibly some volume depletion and not sepsis. Only SIRS criteria was leukocytosis. Initial concern for tamponade but no evidence of evolving effusion on echo. Valsartan dose decreased to 40mg Daily from 80mg [Hospital1 ]. Lasix dose decreased from 80mg Daily from [Hospital1 ]. 2. Acute on chronic renal failure: The patient's Cr is now resolving to 1.7 from a peak of 2.6 vs a baseline of ~ 1.4. Most likely cause is pre-renal exacerbated by high levels of [Last Name (un) ] and hypotension. 3. Leukocytosis: Improving. 17.2 on admission --> 13.9 day discharge. UA negative. No clinical symptoms of pneumonia and CXR suggests atelactasis. Afebrile throughout admission. Cultures negative on discharge. 4. Pericardial Effusion: New pericardial effusion on CT scan not present three weeks ago but without significant effusion on echo. No clinical symptoms of tamponade. 5. Atrial fibrillation: Currently in NSR. Patient had newly diagnosed Afib on his last admission ~ 4 weeks prior to the current admission. Continue diltiazem and digoxin. 6. INR elevated 3.8 on day of discharge, recommended to hold coumadin on day of discharged and start decreased coumadin dose 2 mg on [2132-11-13]. 7. Type 2 diabetes mellitus: Patient has difficult to control diabetes and is followed at the [Last Name (un) ]. His most recent A1c was 8.3%. Was on Insulin 100 units TID 8. Diastolic CHF: No sign of acute CHF episode. Continued outpatient medications. Decreased Lasix to 80mg Daily from [Hospital1 ]. Can increase if patient becomes fluid overloaded. Recommend daily weights and strict I/O, if becomes positive increase Lasix. Patient will follow up with cardiology Dr. [Last Name (STitle) ] in [1-11] weeks. 9. Elevated transaminases: Stable from prior admission when changes consistent with fatty liver were seen on ultrasound. 10. Depression: Patient reports poor mood and satisfaction. TSH was normal. He was continued on his Effexor and Celexa. 11. Hyperlidemia: Continued rosuvastatin and niacin. 12. GOUT: Continued Allopurinol 13. COPD: continue Advair, albuterol and ipratropium. 14. History of CVA: Continue plavix. 15. OSA: Pt refuses to use CPAP Medications on Admission: MEDICATIONS AT HOME (per [Hospital1 599]): - Allopurinol 300mg daily - Carvedilol 25mg [Hospital1 ] - Clopidogrel 75mg daily - Digoxin 125 mcg QOD, alternating with 250mcg - Diltiazem SR 360mg daily - Duloxetine DR 20mg [Hospital1 ] - Advair 100-50 1 puff [Hospital1 ] - Furosemide 80mg [Hospital1 ] - Insulin humalog SS - Humulin 22 units daily ((- Insulin Regular Hum U-500 120units QAM, 110 units Qnoon, 110units QPM.)) - Duoneb Q6hrs PRN - Multivitamin 1 tablet daily - Niacin 500mg SR - Ranitidine 300mg daily - Rosuvastatin 40mg daily - Valsartan 80mg [Hospital1 ]?? - Warfarin 3.5mg daily - Acetaminophen 650mg Q6hrs PRN - Milk of Mag 30mg daily PRN - Fexofenadine 60mg [Hospital1 ] Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 3. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO QHS (once a day (at bedtime)). 6. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. Insulin Regular Hum U-500 Conc 500 unit/mL Solution Sig: One Hundred (100) units Injection TID w/ meals (). 12. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: max 4 grams a day. 13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for wheezing. 15. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Hold for SBp < 100. 16. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 17. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 18. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for SBP < 90. 20. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for SBP < 90. 21. Diltzac ER 360 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day: Hold for SBP < 90, HR < 60. 22. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Start [2132-11-13]. Due to elevated INR 3.8 holding dose [2132-11-12]. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] Discharge Diagnosis: 1. Hypotension 2. Diastolic Heart Failure 3. Prerenal acute renal failure on CKD 4. Pericardial effusion without tamponade 5. Type 2 diabetes mellitus 6. Atrial fibrillation 7. Gout Discharge Condition: Good Discharge Instructions: You were admitted for low blood pressure which was felt to be secondary to blood pressure medication because of this we have decreased your Valsartan. We have made changes to your medication - please follow the list given to rehab. Follow-up with your primary care doctor and cardiologist. Call your doctor if you experience dizziness, chest pain, shortness of breath or any other concerning symptoms. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Adhere to 2 gm sodium diet. You are being discharged to [Hospital 100] Rehab. Followup Instructions: Appointments scheduled: Provider: [First Name11 (Name Pattern1) 3688] [Last Name (NamePattern4) 10476], MD Phone:[Telephone/Fax (1) 612] Date/Time:[2132-12-23] 11:30 Schedule an appointment with your cardiologist Dr. [Last Name (STitle) ] in [1-11] weeks. Schedule an appointment with your primary care doctor [First Name (Titles) ] [Last Name (Titles) ]e from rehab. Dr. [First Name (STitle) ] [Location (un) ] COMMUNITY HEALTH CENTER [0-0-] Completed by:[2132-11-12]	[ "428.32", "518.0", "327.23", "428.0", "438.89", "491.20", "416.8", "285.21", "288.60", "403.90", "E942.9", "311", "585.3", "V58.61", "790.92", "E934.2", "423.9", "728.89", "274.9", "250.02", "458.29", "427.31", "278.00", "584.9" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	10803, 10888	5238, 7889	292, 298	11113, 11119	2874, 2879	11745, 12265	2394, 2506		8658, 10780		10909, 11092		7915, 8635			11143, 11722									2521, 2855																								241, 254			3483, 5215							326, 1608									2893, 3464						1630, 1860	1876, 2378
29,141	172,116	46807	Discharge summary	report	Admission Date: [2163-12-15] Discharge Date: [2163-12-21] Date of Birth: [2088-12-17] Sex: M Service: MEDICINE Allergies: Neosporin Attending:[First Name3 (LF) 898] Chief Complaint: Respiratory Distress, tachycardia Major Surgical or Invasive Procedure: none History of Present Illness: 74 yo with hx of CHF (EF 50%), DM, COPD, with [Month (only) 205] admission for respiratory distress attributed to PNA + COPD/CHF exacerbation, on home 2-3L O2, found unresponsive in bed by wife on [12-15]. EMS tried to intubate, elicited gag reflex, and patient woke up. Seen at [Location (un) 620], vitals T 99.8, HR 135, irreg, RR 30, BP 114/71, O2 sat 100% on NRB. CXR thought to be c/w CHF vs PNA and given lasix 40mg IV, 60mg prednisone, combivent nebs, ceftriaxone, respiratory status improved. ABG 7.29/80/86 on NRB. He was then transferred to [Hospital1 18]. . In [Hospital1 18] ED, vitals T 99.8, BP 114/71, HR 139, RR 28, O2 sat 98% on 3L by NC. ABG 7.35/67/88/39 and placed on CPAP 5/5 and 0.4, with repeat ABG 7.38/63/92/39. Also given combivent nebs. CXR w/CHF and given lasix 40 mg X 1. Also received Azithromycin for PNA given dark yellow sputum. . Admitted to the MICU, where he denies fever, chest pain, abdominal pain, dysuria, increased cough, or increased peripheral edema. Denies sick contacts. Past Medical History: - CHF: EF 50% 5/07 with dilated left atrium, 1+ MR. [First Name (Titles) ] [Last Name (Titles) 5348] he sleeps with 3 pillows. - COPD: on 2.5-3L NC home O2, [Last Name (Titles) 5348] 10mg prednisone daily, recent admit for exacerbation [6-13] with steroid taper. Has had [4-10] hospitalizations for COPD in last 3 years, never intubated - Atrial Fibrillation (on coumadin 2.5 mg): INR 1.6 at [Location (un) 620] - Neuropathy with chronic pain - Lung cancer, diagnosed 5 years ago, s/p resection of ?R lung per family [4-10] yrs ago - depression - hiatal hernia - Tracheobronchomalacia per previous CT - Small cystic lesions in the liver and kidneys, incompletely characterized. Social History: He lives with his wife, 60 pack-year smoking hx, quit 30 yrs ago, social drinker. Family History: Non-contributory Physical Exam: VS: 99.1 98 94/49 18 98% 4LNC general: alert, pleasant, comfortable heent: PERRL, dry MM neck: no JVD appreciated, supple chest: [Last Name (un) 3526] irregular, II/VI systolic murmur lungs: coarse rales throughout abd: ND, NT +BS ext: venous stasis changes, trace edema at the ankles, 2+ DP pulses, no cyanosis/clubbing neuro: AOx3 Pertinent Results: from [Location (un) 620]: WBC 13.0, 85, no bands, Hct 38.4 Sputum sample contaminated . CXR portable [12-15]: There are low lung volumes. There is persistent elevation of the right hemidiaphragm. There are no consolidations or effusions. There is no pneumothorax. Linear area of scarring is seen in the right upper lobe. There is right lower lobe atelectasis. The cardiomediastinal and hilar contours are stable. . CXR PA & lateral [12-18]: Vascular congestion and cardiomegaly are borderline unchanged since [12-15]. There is no pleural effusion. Lung volumes remain low, particular on the right where there is relative elevation of the lung base, with disparity more pronounced now than it was in [Month (only) 205], probably due to progressive diaphragmatic eventration. . Admission labs [2163-12-16] 01:09AM BLOOD WBC-8.6 RBC-4.31* Hgb-11.9* Hct-36.3* MCV-84 MCH-27.6 MCHC-32.7 RDW-15.5 Plt Ct-184 [2163-12-16] 01:09AM BLOOD Neuts-88.5* Lymphs-7.7* Monos-3.7 Eos-0.1 Baso-0 . [2163-12-16] 01:09AM BLOOD Glucose-108* UreaN-33* Creat-1.3* Na-135 K-4.7 Cl-93* HCO3-33* AnGap-14 [2163-12-16] 01:09AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.4 . [2163-12-16] 01:09AM BLOOD PT-20.9* PTT-32.4 INR(PT)-2.0* . Discharge labs [2163-12-21] 05:35AM BLOOD WBC-11.5* RBC-4.38* Hgb-11.9* Hct-37.0* MCV-84 MCH-27.2 MCHC-32.2 RDW-15.9* Plt Ct-297 . [2163-12-21] 05:35AM BLOOD Glucose-89 UreaN-28* Creat-1.0 Na-140 K-3.9 Cl-94* HCO3-39* AnGap-11 [2163-12-21] 05:35AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.4 . [2163-12-21] 05:35AM BLOOD PT-29.4* PTT-31.0 INR(PT)-3.0* . Cardiac labs [2163-12-16] 01:09AM BLOOD proBNP-1779* . [2163-12-17] 02:20PM BLOOD CK(CPK)-141 CK-MB-5 cTropnT-0.03* [2163-12-18] 07:15AM BLOOD CK(CPK)-88 CK-MB-NotDone cTropnT-0.03* [2163-12-18] 03:00PM BLOOD CK(CPK)-107 CK-MB-5 cTropnT-0.02* . Blood gases [2163-12-15] 12:43PM BLOOD Type-ART Temp-38.0 pO2-88 pCO2-67* pH-7.35 calTCO2-39* Base XS-7 Intubat-NOT INTUBA [2163-12-15] 07:59PM BLOOD Type-ART Rates-/26 O2 Flow-6 pO2-92 pCO2-63* pH-7.38 calTCO2-39* Base XS-8 Intubat-NOT INTUBA Comment-NASAL [Last Name (un) 154] [2163-12-17] 10:00AM BLOOD Type-ART pO2-71* pCO2-54* pH-7.46* calTCO2-40* Base XS-12 Brief Hospital Course: # Respiratory distress/COPD: The patient presented in hypercarbic respiratory failure, with a pCO2 in the 80s. A chest X-ray at the outside hospital was read as possible CHF or pneumonia. He was treated for both diagnoses, and given lasix 40mg IV, 60mg of prednisone, Combivent nebs, and ceftriaxone. . A repeat CXR at [Hospital1 18] was questionable for CHF and there was no focal infiltrate. His report of green sputum was thought to represent a COPD flare. Antibiotic coverage was changed to azithromycin, which he completed a 5 day course. He was also given systemic steroids, which were tapered to 20 mg prednisone prior to discharge. His regimen of inhaled medications were optimized with long-acting beta-agonists, anticholinergics, and steroids. . # CHF - The patient has a h/o CHF w/ a dilated left atrium and EF of 50%. A CXR at the OSH was reported as heart failure. The patient was diuresed with 40mg IV lasix. In the ED here, he received a second dose of 40mg IV Lasix. However, on admission to the MICU his creatinine was noted to have increased to 1.3, and his home lasix and spironolactone were held. After he clinically stabilized on the floor, he received IV lasix 80mg for four days for bibasilar crackles and lower extremity edema. He was continued on beta-blocker and ACE inhibitor, and transitioned back to his home PO Lasix prior to discharge. . # Atrial fibrillation/flutter: The patient has a known history of AF on bisoprolol 2.5mg qday. However, in the setting of his acute respiratory illness, his HR rose to the 130's-140's. He received additional beta blockade with 5mg of Lopressor IV, but with little effect. He responded well to IV diltiazem, and was started on PO Diltiazem 30mg QID. This was titrated up and converted to 240mg of long-acting Diltiazem with good effect. His HR was in the 70-80s at discharge. He will need to follow up with his cardiologist to evaluate the effect of the medication, as there is the possibility that as the CHF resolves less rate control will be needed. At [Location (un) 620], his INR was 1.6, and he was continued on his home dose of coumadin. However, his INR became supratherapeutic during his hospitalization, presumed due to concomitant antibiotic therapy. He was discharged on 3mg of Coumadin daily. . # Acute Renal Failure: The patient was noted to be in acute renal failure with a creatinine of 1.3 on admission after receiving 2 [Location (un) 4319] of IV lasix. Both Lasix and spironolactone were held because prerenal azotemia was suspected. The patient received gentle IV hydration and his creatinine normalized to 0.9. As noted above, he received several [Location (un) 4319] of IV lasix after he clinically stabilized on the floor, for bibasilar crackles and lower extremity edema. He was transitioned back to his home lasix and spironolactone prior to discharge. . # CAD: An EKG was performed and did not show active ischemia. Cardiac enzymes were sent and were negative X3. The patient was continued on aspirin, statin, lopressor, and lisinopril. . # Neuropathy. This was not an active issue, and the patient was continued on his home dose of fentanyl patch, gabapentin, and percocet. . # Depression: This was not an active issue. The patient was continued on his home sertraline . # FEN: The patient was placed on a cardiac/heart healthy diet. Medications on Admission: Aspirin 81 mg PO DAILY Atorvastatin 80 mg DAILY Lisinopril 5 mg PO DAILY Metoprolol 25 [Hospital1 ] or ?Bisoprolol 2.5 mg daily Prednisone 10 mg PO daily starting [7-2] Warfarin 3mg MWF; 4 mg STThS Fentanyl 50 mcg/hr Q72H Gabapentin 300 mg po TID Furosemide 20 mg TID-->he takes 40-120 depending on his assessment of his swelling Spironolactone 50 mg PO QOD Sertraline 50 mg PO daily Tamsulosin 0.4 mg PO HS Combivent 103-18 mcg, 1-2 puffs, [Hospital1 ] Multivitamin Cyanocobalamin 500 mcg DAILY Potassium Chloride 20 mEq [Hospital1 ] atrovent albuterol percocet prn Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72 hour (). 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:1 Disk with Device(s) Refills:2 11. Bisoprolol Fumarate 5 mg Tablet Sig: 0.5 Tablet PO daily (). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas. 15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO twice a day as needed for constipation. 16. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day. 17. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO EVERY OTHER DAY (Every Other Day). 18. Albuterol 90 mcg/Actuation Aerosol Sig: [2-8] Inhalation every 4-6 hours. 19. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:30 Cap(s) Refills:2 20. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath. 21. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. Furosemide 40 mg Tablet Sig: 2-3 Tablets PO DAILY (Daily). 23. Outpatient [Name (NI) ] Work PT, PTT, INR on Friday, [2163-12-23]. Results sent to Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 6163]. 24. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO once a day. Tablet(s) 25. Diltiazem HCl 240 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. Disp:30 Capsule, Sust. Release 24 hr(s) Refills:2 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Primary Diagnosis: COPD exacerbation Secondary diagnoses: Acute renal failure CHF Atrial fibrillation w/ RVR Depression Coronary artery disease Peripheral neuropathy Discharge Condition: stable Discharge Instructions: You were seen in the hospital because you were found unconscious with an elevated carbon dioxide level. We think that this may be related to a flare of your COPD. While in the hospital, you were found to have a rapid heart rate. You were given diltiazem for your heart rate which you will take once a day. We made some changes to your breathing medications. We stopped Combivent and Fluticasone. You will now take Advair twice a day and Spireva once a day. You will continue to use your Albuterol inhaler every 4-6 hours as needed. Your INR (a measure of your blood clotting) was high while in the hospital. We decreased your Coumadin to 3mg every day. You will need to follow up with your doctor to have your INR checked next week. You are also now on 20mg of prednisone daily. You should follow up with your primary care physician to determine if you should stay on this dose of steroids. If you experience worsening shortness of breath, chest pain, feel your heart going fast, or have any concerning symptoms, please call your primary care provider or return to the emergency room. You should make appointments to follow up with your primary care physician. [Name10 (NameIs) ] should also have your INR checked this Friday ([12-23]). The results will be sent to your primary doctor, who you should follow up with regarding titration of your coumadin dose. Followup Instructions: Please make an appointment to follow up with your primary care physician next week, [First Name8 (NamePattern2) 30642] [Doctor Last Name ] at [Telephone/Fax (1) 6163]. Completed by:[2164-1-19]	[ "355.9", "584.9", "518.81", "428.33", "V58.65", "V58.61", "428.0", "427.31", "427.32", "491.21", "V10.11", "250.00" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	11275, 11324	4872, 8218	306, 312	11534, 11543	2611, 4849	12960, 13170	2221, 2239		8851, 11252		11345, 11345		8244, 8828			11567, 12937									2254, 2592			11403, 11513																					233, 268										340, 1377								11364, 11382							1399, 2106	2122, 2205
67,458	155,586	38878	Discharge summary	report	Admission Date: [2134-3-16] Discharge Date: [2134-3-18] Date of Birth: [2058-7-11] Sex: M Service: MEDICINE Allergies: Naproxen Attending:[First Name3 (LF) 3531] Chief Complaint: abdominal pain, nausea, vomiting Major Surgical or Invasive Procedure: ERCP with 2 plastic stents placed - [2134-3-17] History of Present Illness: 75M with DM, CHF, CKD, Afib, presenting to [Hospital ] Hospital on [3-15] with abdominal pain, nausea and vomiting, now transfer to [Hospital1 18] for ERCP. He went to bed on the evening of [3-13] and awoke an hour later with severe RUQ pain. He had several episodes of bilious vomiting that night and the following day (sunday), about 6-7 times total. He presented to the OSH on [3-15] and was noted to be jaundiced with abnormal LFTs (total bili 5.4, direct 4.3). CT abdomen showed a distended gallbladder, gallstones, biliary and gallbladder air. He was started on unasyn and ceftriaxone and plans made for transfer for ERCP for presumed CBD stone. He was admitted to the ICU for reversal of anticoagulation (got 2 units FFP last night) but never had any HD instability. . On arrival to the ICU floor the patient appeared comfortable and denied any current RUQ pain, shortness of breath, or nausea. . Review of sytems: (+) Per HPI, + low grade fever earlier in course. (-) Denies recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied diarrhea or constipation. No dysuria. Denied arthralgias or myalgias. Past Medical History: Diabetes mellitus type 2 - CKD - baseline creatinine unknown - Afib - CAD s/p MI x 2 and CABG [2124] - Congestive heart failure, ischemic, EF 30% - s/p ICD and PPM, placed in [2130] at [Hospital1 2025] - Hyperlipidemia - BPH - Gout - Colon polyps - Meningioma Social History: Married, lives at home in [Location (un) ] with wife. Quit smoking 40+ years ago. EtOH intake of 1 drink per week. Part-time monitor. Family History: Mother died of MI at 76, father died of lung cancer at 79. One sister with diabetes. Physical Exam: Vitals: T: 99.4 BP: 130/61 P: 68 R: 32 O2: 94% RA General: Elderly Caucasian male, slightly tachypneic in no acute distress HEENT: + scleral icterus, MMdry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic murmurs, well-healed median sternotomy scar and pacemaker pocket scar near the left shoulder with pacemaker palpable subcutaneously in the left upper chest. Abdomen: absent bowel sounds, soft, + RUQ tenderness, no rebound or guarding GU: + foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [2134-3-17] 10:36 AM IMPRESSION: Gallbladder stones. Gallbladder wall appears normal. Air within the gallbladder. ERCP BILIARY&PANCREAS BY GI UNIT Study Date of [2134-3-16] 8:54 PM Impression: - Multiple ulcers in the duodenal bulb and second part of the duodenum with some oozing of blood. - Normal major papilla. - Cannulation of the pancreatic duct was performed with a sphincterotome after a guidewire was placed. Contrast medium was injected resulting in partial opacification. This was performed in order to place a pancreatic duct stent to facilitate biliary cannulation. - The major papilla was cannulated and a normal caliber distal pancreatic duct was visualized. The main pancreatic duct was short and truncated with arborization proximally. The minor papilla was not cannulated. These findings are consistent with pancreas divisum. - A 5FR x 4cm plastic pancreatic duct stent was placed successfully to facilitate biliary cannulation, and was removed successfully using a snare prior to the placement of the biliary stent. - Cannulation of the biliary duct was performed with a sphincterotome after a guidewire was placed and with a PD stent in place as the cannulation was difficult. Contrast medium was injected resulting in complete opacification. - A mild diffuse dilation was seen at the main duct with the CBD measuring 7-8 mm. There were no stones or strictures. These findings are compatible with a normal CBD for his age. - A 7cm by 10FR biliary stent was placed successfully. - A small amount of biliary sludge was seen at the ampulla during cannulation. However, once the biliary stent was placed clear bile without sludge or pus drained fomr the stent. - The cystic duct was not visualized during the procedure as it did not fill with contrast. CBC [2134-3-18] 05:40AM BLOOD WBC-8.5 RBC-4.01* Hgb-11.4* Hct-34.5* MCV-86 MCH-28.4 MCHC-33.0 RDW-15.0 Plt Ct-153 [2134-3-17] 04:20AM BLOOD WBC-8.9 RBC-3.69* Hgb-10.9* Hct-32.4* MCV-88 MCH-29.5 MCHC-33.7 RDW-15.0 Plt Ct-128* [2134-3-16] 02:37PM BLOOD WBC-10.4 RBC-4.26* Hgb-12.4* Hct-37.6* MCV-88 MCH-29.2 MCHC-33.1 RDW-14.5 Plt Ct-167 Coags [2134-3-18] 05:40AM BLOOD PT-24.7* PTT-27.6 INR(PT)-2.4* [2134-3-17] 04:20AM BLOOD PT-23.3* PTT-27.5 INR(PT)-2.2* [2134-3-16] 02:37PM BLOOD PT-21.5* PTT-24.7 INR(PT)-2.0* Chemistry [2134-3-18] 05:40AM BLOOD Glucose-81 UreaN-39* Creat-1.7* Na-141 K-4.1 Cl-107 HCO3-25 AnGap-13 [2134-3-17] 04:20AM BLOOD Glucose-77 UreaN-43* Creat-1.7* Na-144 K-4.2 Cl-109* HCO3-22 AnGap-17 [2134-3-16] 02:37PM BLOOD Glucose-71 UreaN-44* Creat-2.1* Na-144 K-4.0 Cl-106 HCO3-26 AnGap-16 [2134-3-18] 05:40AM BLOOD Calcium-8.8 Phos-2.5* Mg-2.1 [2134-3-17] 04:20AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.9 [2134-3-16] 02:37PM BLOOD Calcium-9.0 Phos-2.8 Mg-2.0 LFTs [2134-3-18] 05:40AM BLOOD ALT-86* AST-39 LD(LDH)-161 AlkPhos-186* TotBili-1.3 [2134-3-17] 04:20AM BLOOD ALT-102* AST-67* AlkPhos-149* TotBili-1.6* DirBili-1.2* IndBili-0.4 [2134-3-16] 02:37PM BLOOD ALT-120* AST-72* LD(LDH)-200 AlkPhos-158* Amylase-28 TotBili-2.3* DirBili-1.8* IndBili-0.5 Brief Hospital Course: 75M with DM2, CKD, Afib, CHF, presenting with abdominal pain, N/V, found to be jaundiced with elevated bilirubin and transaminases with pneumobilia, transferred for ERCP. # Pneumobilia, Abdominal pain: Patient was transferred to the [Hospital1 18] from [Hospital ] Hospital after presenting to their hospital with abdominal pain, nausea, vomiting and found to have a leukocytosis, elevated bilirubin and transaminases concerning for biliary tree obstruction. He was started on Unasyn at [Hospital ] Hospital and was transferred to the [Hospital1 18] for an ERCP. He underwent ERCP on [3-16] that demonstrated oozing duodenal ulcers, but no evidence of stones. Two biliary stents were placed and he was started on a PPI [Hospital1 ]. A serum H. pylori test was sent that was negative and he was continued on Unasyn 3g q8H. General Surgery recommended percutaneous biliary drainage prior to cholecystecomy, but IR did not feel there was an indication for drainage. Following ERCP patient remained hemodynamically stable, afebrile, and both his WBC & LFT's trended down. He tolerated a regular diet. He was discharged home with follow up in general surgery clinic for possibility of outpatient cholecystectomy and GI for management of duodenal ulcers and repeat ERCP to remove stents. Patient was discharged home with 8 more days of cipro and flagyl to complete a 10 day course of antibiotics. #. Duodenal ulcers - Patient discharged with omeprazole 40 mg [Hospital1 ] and has a follow up appointment with GI. Patient was recommended to restart his coumadin for management of his atrial fibrillation despite the finding of oozing duodenal ulcers on ERCP. Patient was warned about risks of GI bleeding and educated as to what to watch out for. Patient will have a repeat CBC drawn on [2134-4-1] when he sees his PCP to monitor his blood counts. # Afib: Patient on Coumadin and Metoprolol as an outpatient. He was continued on his home Metoprolol during admission, but coumadin held for ERCP. Patient will restart coumadin after discharge, but was instructed to hold on taking coumadin 5 days prior to repeat ERCP on [2134-4-13], but to restart it afterwards. # Diabetes: Patient with an unknown HbA1c, but takes 2.5mg Glipizide as an outpatient. He was continued on a humalog insulin sliding scale as an inpatient. # CAD s/p CABG: Patient continued on his home Aspirin, Metoprolol, & Simvastatin # CHF: Patient continued his home Metoprolol. His Lisinopril & Lasix were initially held for hypotension and poor PO intake, but restarted on discharge when his vitals were once again stable and hypertensive. # CKD: Baseline Creatinine of 2 per his PCP. [Name10 (NameIs) ] admission it was 2.1 and trended down to 1.7 at discharge # Hyperlipidemia.: Continued home Simvastatin # Gout: Continued home Allopurinol # Code: Full code Medications on Admission: - ASA 81 mg daily - Lisinopril 2.5 mg daily - Simvastatin 20 mg daily - Allopurinol 300 mg [Hospital1 ] per notes / 150 mg daily per patient - Metoprolol 25 mg [Hospital1 ] - Coumadin 5 mg daily (reports [1-16] tab of ?strength 4x/wk, full 3x/wk) - Glipizide 2.5 mg QAM - Colchicine 0.6 mg prn - Furosemide daily, unclear dose Discharge Medications: 1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 2. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO qAM. 7. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for gout. 8. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 8 days. Disp:16 Tablet(s) Refills:0 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three times a day for 8 days. Disp:24 Tablet(s) Refills:0 10. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO qMon, Wed, Fri. 12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO qSun, Tues, Thurs, Sat. 13. Outpatient Lab Work Please draw a CBC on [2134-4-1] and fax results to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9145] at [Telephone/Fax (1) 86276]. Your last hematocrit at discharge was 34.5 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Choledocolithiasis Secondary Diagnosis: Diabetes Mellitus CKD - baseline creatinine of 2 Afib on warfarin CAD s/p MI x 2 and CABG [2124] Congestive heart failure, ischemic, EF 30% s/p ICD and PPM, placed in [2130] at [Hospital1 2025] Hyperlipidemia Gout Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted to [Hospital1 69] because of abdominal pain, nausea, and vomiting. These are likely due to gallstones. You were seen by the GI doctors during your [Name5 (PTitle) ], and an ERCP was performed to further evaluate your symptoms. Two plastic stents were placed in your bile ducts, which will need to be removed at a later time. You were also evaluated by the surgeons who did not think that you needed an emergent gall bladder removal. You will need to follow up with surgery in order to be worked up for gall bladder removal as an outpatient. Your medications have changed, please make note of the following changes: - omeprazole 40 mg twice a day - ciprofloxacin - metronidazole The rest of your medications have not changed. Please continue to take them as originally prescribed. *Please hold on taking your coumadin 5 days prior to your repeat ERCP procedure ([Date range (1) 85977]). You can restart coumadin after the procedure is done* Please keep all your medical appointments. Appointments were made for you to see your PCP, [Name10 (NameIs) ], and surgery. Please have your blood counts drawn on [2134-4-1], the day that you will be seeing your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 9145] If you experience chest pain, shortness of breath, notice blood in your stools, or have worsening abdominal pain, please return to the emergency room. Followup Instructions: Appointment #1 MD: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9145] Specialty: Internal Medicine-Primary Care Date/ Time: [2134-4-1] 10:00am Location: [Location (un) 86277], [Location (un) 4047] MA Phone number: [Telephone/Fax (1) 9146] Appointment #2 MD: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2643] Specialty: Gastroentereology Date/ Time: [2134-4-6] 10:00am Location: [Last Name (NamePattern1) 439] [Hospital Unit Name ] [Location (un) 858] Suite E, [Location (un) 86] MA Phone number: [Telephone/Fax (1) 463] Appointment #3 MD: Dr. [First Name4 (NamePattern1) 449] [Last Name (NamePattern1) ] Specialty: Surgery Date/ Time: [2134-4-6] 2:30pm Location: [Last Name (NamePattern1) 439] [Hospital Unit Name ] [Location (un) ] Suite A, [Location (un) 86] MA Phone number: [Telephone/Fax (1) 10693] Appointment #4 MD: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Specialty: Gastroentereology Date/ Time: [2134-4-13] 09:30a Location: [First Name8 (NamePattern2) ] [Hospital Ward Name ] BUILDING ([Hospital Ward Name ]/[Hospital Ward Name ] COMPLEX), [Location (un) ] ENDOSCOPY SUITES	[ "428.22", "532.90", "V45.02", "585.9", "250.00", "V45.81", "414.00", "274.9", "574.20", "428.0", "272.4" ]	icd9cm	[ [ [] ] ]	[ "51.85", "52.93" ]	icd9pcs	[ [ [] ] ]	10622, 10628	6065, 8949	302, 356	10957, 10957	2879, 6042	12556, 13819	2104, 2190		9339, 10599		10649, 10649		8975, 9316			11105, 12533									2205, 2860																								230, 264				1326, 1636						384, 1308				10708, 10936				10668, 10687			10972, 11081				1659, 1933	1949, 2088
74,032	194,794	41395	Discharge summary	report	Admission Date: [2150-3-22] Discharge Date: [2150-4-21] Date of Birth: [2083-9-7] Sex: F Service: NEUROSURGERY Allergies: Lipitor / cefazolin Attending:[First Name3 (LF) 78] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: [2150-3-22]: R EVD placement [2150-3-23]: Cerebral angiogram with coiling of PCOMM aneurysm [2150-4-8]: VP shunt placement [2150-4-17]: PEG tube placement History of Present Illness: This is a 66 year old woman who developed vomiting after church the morning of presentation. Per her husband, she went to lie down and around 4pm was found by husband in bed to be sleepy and covered with vomitus. She did not complain of headache to husband. [Name (NI) ] cleaned the patient, offered her coffee but patient vomited again and became progressively unresponsive and husband initiated EMS. She was taken to OSH where she was intubated for unresponsiveness. Head CT documented around 6:45pm showed diffuse subarachnoid hemorrhage, IVH and hydrocephalus. She was transfered to [Hospital1 18] for further evaluation. Past Medical History: hypothyroid, hyperlipidemia, s/p cholecystectomy, s/p craniotomy (unknown history at this time), ? right ear surgery Social History: Lives with husband, supportive family nearby. Family History: non-contributory Physical Exam: On admission: PHYSICAL EXAM: Hunt and [Doctor Last Name 9381]: 4 [Doctor Last Name ]: 4 GCS E:1 V:1 Motor:4 O: T: BP:117/72 HR: 80 R O2Sats98% Gen: Intubated HEENT: Pupils: 2mm-1mm Neck: Supple. Extrem: Warm and well-perfused. No C/C/E. Neuro: Pupils equal and reactive 2mm to 1mm Bilaterally Positive corneals bilaterally Positive cough Motor: Normal bulk and tone bilaterally. No movement of upper extremities to deep stim Minimal withdrawal of Lower extremities bilaterally to noxious On Discharge: AFVSS Gen: pleasant and cooperative, she is smiling and pleasant HEENT: right head shaved and incision appears c/d/i, PERRL Neck - supple COR: RRR, S1 s 2 nl, no murmurs Lungs: CTAB, no w/c/r Abd: left G-tube in place c/d/i, soft, + BS Extremetity - no c/c/e Neuro: AAOx3, PERRL, EOM intact, motor - full, sensory - full, gait antalgic, no drift, face symmetric. reflex 2+, no clonus Pertinent Results: [2150-3-22] Head CT: Diffuse subarachnoid hemorrhage along both sylvian fissures, extending into the suprasellar and prepontine cistern. There is intraventricular extension of hemorrhage with hemorrhage seen pooling in the occipital [Doctor Last Name 534] of both lateral ventricles, the third ventricle and extending into the fourth ventricle. There is unchanged hydrocephalus of all visible ventricles. The extent of the subarachnoid, intraventricular hemorrhage and hydrocephalus is unchanged compared to the prior examination. A small amount of hemorrhage is also noted between both frontal lobes. No subdural hemorrhages are noted. The visible paranasal sinuses and mastoid air cells are well aerated. No fractures are present. [2150-3-22] Head CT: Right frontal approach ventriculostomy catheter in appropriate position. Unchanged subarachnoid and intraventricular hemorrhage as described above. Final Attending comment: There is a lesion in the clivus with permeative bony destruction. [2150-3-23] Head CT: IMPRESSION: 1. Diffuse subarachnoid hemorrhage and intraventricular hemorrhage layering along the occipital horns. Overall unchanged in extent since examination from [2150-3-22]. No associated mass effect with no shift of the normally midline structures. The patient is status post right frontal approach ventriculostomy catheter in unchanged position with unchanged enlargement of the ventricular system. 2. 4-mm focal wide-necked aneurysm arising from the right posterior communicating artery. 3. Diffuse long segment narrowing of the basilar artery likely related to either vasospasm or vasculitis. 4. Large 2.5 cm predominantly lytic mass arising from the right posterior aspect of the clivus with associated bony destruction and overall with heterogeneity and cystic components. This mass extends from the right posterior aspect of the clivus to involve the right jugular foramen.There is denervation of the right hemitongue. Differential diagnosis includes likely chondrosarcoma though metastasis is not excluded and tumors arising from the jugular foramen such as paraganglioma/schwannomas are also not excluded. [2150-3-26] CTA/CTP Head: IMPRESSION: 1. Persistent subarachnoid hemorrhage and intraventricular hemorrhage with persistent moderate dilation of the lateral and the third ventricles. To check with catheter function. 2. No area of perfusion deficit in the imaged portions of the brain. 3. Narrowing of the M1 and M2 and A1 and A2 segments of the middle cerebral and the anterior cerebral arteries on both sides, likely related to vasospasm compared to the prior CTA study. 4. Right skull base leison invlving the right IJV,as above- consider MR if not CI, when appropriate. [2150-3-28] CTA Head: IMPRESSION: Slightly worsening anterior circulation vasospasm compared with the previous CTA examination of [2150-3-26]. However, the vasospasm remains nonocclusive and no evidence of vascular occlusion seen in the arteries of anterior or posterior circulation. Post-embolization changes are again noted. Head CT again demonstrates blood in the ventricles and subarachnoid spaces with ventricular dilatation. [2150-3-30]: Dopplers lower extremities IMPRESSION: No evidence of deep venous thrombosis in the lower extremities [2150-3-30] CTA IMPRESSION: 1. Expected evolution of subarachnoid hemorrhage without evidence of rebleeding. 2. Stable intraventricular hemorrhage and stable ventricular enlargement. Unchanged position of the right frontal ventriculostomy catheter. 3. Marked improvement in vasospasm in the anterior circulation. 4. Unchanged irregular narrowing of the distal basilar artery, which could be related to persistent vasospasm. [2150-3-31] EEG: IMPRESSION: This telemetry captured no epileptiform discharges or electrographic seizures. It showed a normal background in wakefulness and in sleep. [2150-4-2] CT CHEST ABD PELVIS IMPRESSION: 1. No cause for the patient's fever identified. 2. Small-to-moderate left pleural effusion and associated atelectasis, which has increased over the past several days when compared to chest radiographs. 3. Right-sided aortic arch with aberrant left subclavian, which can cause symptoms of dysphagia or dyspnea. [2150-4-3] CT CTA BRAIN IMPRESSION: 1. Expected evolution of intracranial hemorrhage, without evidence of interval hemorrhage. 2. Marked improvement of previously seen anterior circulation and basilar vasospasm. 3. Redemonstration of a large lytic lesion at the right [Last Name (un) ]-clival syndchondrosis. By location, this is concerning for a chondrosarcoma. 4. Unchanged position to a right frontal ventriculostomy catheter. [2150-4-5] CXR Lines and tubes are stable. There is a prominence of cardiac silhouette and mediastinum. There is old healed right-sided rib fracture. No focal consolidation or pleural effusions or overt pulmonary edema is seen. [2150-4-9] Head CT: Stable appearance of ventricular size. Inteval placement of VP shunt. Catheter in the R lateral ventricle. Stable appearance of known ICH. No new acute blood. [2150-4-10] Head CT: No significant change in ventricular size. [4-16] Video swallow - IMPRESSION: No gross aspiration or penetration. However, significant pharyngeal dysfunction with residue in the right piriform sinus. Please see speech and swallow division note for details. Brief Hospital Course: 66F who was admitted with a SAH and IVH extension. A EVD was emergently placed given the imaging and exam. She was admitted to the Neuro-ICU. A CTA was then performed which confirmed a PCOMM aneurysm. On [2150-3-23], the patient underwent a cerebral angiogram with coiling. Post-angio she was extubated. THe EVD was maintained at 20cm above the tragus. Extubated, she was more awake but confused, speech appeared slurred. [3-26] patient was found in the morning with high fevers, diffuse macluar papular rash on her chest legs above her knees. This was associated with Ancef which she was recieving to cover her for EVD. Ancef was discontinued and Vancomycin was started for gram positive coverage. patient was pan cultured. 24 hour EEG was placed to monitor for any early signs of vasospasm and stroke. A CTA was obtained which did not reveal significant vasospams. On [3-27] she continued with fevers and Cipro and Gent was added to cover for possible aspiration pneumonia. On [3-28] she had a repeat CTA which showed possible minimal vasospasm. EEG was discontinued on [3-28]. On [3-29] levophed was added to help drive her SBP > 160. Her strength appeared improved. On [3-30] her overall exam was improved and a repeat CTA/CTP was performed. On [4-1] patient had persistant fevers with a WBC of 28. Her bld cultures, urine cultues and CSF gram stains have been negative to this date. An ID consult was called to work up her fever source and to obtain clearence for possible VPS placement. She failed several clamping trials throughout the day. Her VPS was placed on hold secondary to persistnet fevers and leukocytosis. ID Recs were followed and her Flagyl, Gent and meropenum were discontinued because no obvious fever source was found on [4-7]. On [4-6] her serum NA was 132 and daily serum NA checks were down, ASA was discontinued. On [4-7] Keppra was discontinued. On [4-8], she was taken to the OR for a VP shunt. Post-operatively, the patient was transferred to the floor from PACU. Post-op CT was stable and patient was evaluated by PT and OT. Speech and swallow eval was done at bedside but patient failed. A video swallow was done on [2150-4-10] which showed moderate oral and severe pharyngeal dysphagia. Patient exam improved from [Date range (1) 90093] and on [4-14] a repeat bedside swallow evaluation showed [Known lastname ] overt signs of aspiration. The family was still refusing a PEG as pt is reported with baseline swallow difficulty. They agreed to contemplate this decision further. A video swallow eval was planned for [4-16]/ On [4-15], her cnetral line was removed. On [4-16] patient failed another Video swallow and went to the OR on [4-17] for PEG placement. On [4-18] she remained stable. TF's were initiated at 4PM. Sodium supplementation was decreased. On [4-19] Pt had one episode of vomiting. Her be was elevated and patient had no other episodes of vomiting. IVF fluids were initiated due to poor urine output. On [4-20] she continued to remain stable. She continued to be incontinent of urine but was drenching several times a day. As a result, IVF was discontinued. She continued to be on TFs at goal 30cc/hr continuously and tolerated throughout the day. On day of discharge pt remained afebrile, vital signs were stable, tolerating TF at goal 30cc/hr. She is set for d/c the rehab. Medications on Admission: unknown Discharge Medications: 1. acetaminophen 325 mg Tablet [Month/Year (2) ]: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain/fever. 2. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 3. levothyroxine 75 mcg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 4. pravastatin 20 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO HS (at bedtime). 5. aspirin 325 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 6. nystatin 100,000 unit/mL Suspension [Last Name (STitle) ]: Five (5) ML PO QID (4 times a day). 7. bisacodyl 10 mg Suppository [Last Name (STitle) ]: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 8. docusate sodium 50 mg/5 mL Liquid [Last Name (STitle) ]: Two (2) PO BID (2 times a day). 9. senna 8.6 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). 10. sodium chloride 1 gram Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day). 11. camphor-menthol 0.5-0.5 % Lotion [Last Name (STitle) ]: One (1) Appl Topical QID (4 times a day) as needed for rash. 12. heparin, porcine (PF) 10 unit/mL Syringe [Last Name (STitle) ]: One (1) ML Intravenous PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: [Hospital3 17921] Center - [Location (un) 5450], NH Discharge Diagnosis: SAH PCOMM aneurysm LEUKOCYSTOSIS HYDROCEPHALUS ORAL ULCER HYPNATREMIC DYSPHAGIA POST-OPERATIVE FEVER 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: Angiogram with coiling Medications: ?????? Take Aspirin 325mg (enteric coated) once daily. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? You may wash your hair only after sutures and/or staples have been removed. 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 4 weeks with a Head CT w/o contrast. Please call [Telephone/Fax (1) 4296] to make this appointment. Completed by:[2150-4-21]	[ "263.9", "244.9", "272.4", "528.9", "780.62", "693.0", "431", "787.22", "331.4", "112.0", "276.1", "E930.5" ]	icd9cm	[ [ [] ] ]	[ "02.39", "96.71", "39.72", "38.93", "88.41", "96.6", "02.34", "43.11" ]	icd9pcs	[ [ [] ] ]	12599, 12685	7777, 11208	303, 476	12830, 12830	2346, 2362	14893, 15084	1363, 1381		11266, 12576		12706, 12809		11234, 11243			13006, 14212	14238, 14870								1425, 1926																1940, 2327								242, 265										504, 1142					7488, 7754				1410, 1410		12845, 12982				1164, 1283	1299, 1347
28,227	183,668	33966	Discharge summary	report	Admission Date: [2182-4-29] Discharge Date: [2182-5-4] Date of Birth: [2119-10-1] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: Dyspnea on Exertion Major Surgical or Invasive Procedure: Coronary Arterty Bypass Graft x 4 (LIMA>LAD, SVG>Diag, SVG>OM, SVG>PDA) [2182-4-29] History of Present Illness: 62 yo M with worsening DOE. Stress test was abnormal and cardiac cath showed 3VD, he was referred for surgery. Past Medical History: Hypertension, Hypercholesterolemia, Borderline Diabetes, Chronic Obstructive Pulmonary Disease, Benign Prostatic Hypertrophy, Depression, History of kidney stones, History of peptic ulcer disease, s/p Tonsillectomy Social History: tobacco [12-16] ppd x 20 years, quit 22 years ago rare etoh Family History: father deceased early 60s from MI Physical Exam: VS: HR 98 RR 16 BP 110/62 Gen: NAD Skin: Unremarkable Neck: Supple, FROM, -JVD Chest: CTAB Heart: RRR Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, -edema Neuro: grossly intact Pertinent Results: [4-29] Echo: PREBYPASS: No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is moderately dilated with normal free wall contractility. The ascending aorta is mild to moderately dilated. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). POSTBYPASS:Biventricular systolic function is preserved. The study is otherwise unchanged from the prebypass period. [Known lastname ],[Known firstname ] [Medical Record Number 78451] M 62 [2119-10-1] Radiology Report CHEST (PA & LAT) Study Date of [2182-5-2] 9:16 AM [Last Name (LF) ],[First Name7 (NamePattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5204] FA6A [2182-5-2] SCHED CHEST (PA & LAT) Clip # [Clip Number (Radiology) 78452] Reason: eval for pleural effusions [Hospital 93] MEDICAL CONDITION: 62 year old man s/p CABG REASON FOR THIS EXAMINATION: eval for pleural effusions Final Report STUDY: PA and lateral chest radiograph. INDICATION: Status post coronary artery bypass grafting; please evaluate effusions. COMPARISON: [2182-4-30]. FINDINGS: There is severe COPD evidenced by oligemia in the upper lobes and bullous change. Left greater than right effusions are not significantly changed. Lungs remain hyperinflated. Median sternotomy wires and mediastinal clips consistent with coronary artery bypass grafting. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) ] [Doctor Last Name 4391] DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4130] Approved: [Doctor First Name ] [2182-5-2] 10:56 PM Imaging Lab [2182-5-3] 07:55AM BLOOD WBC-8.3 RBC-4.00* Hgb-12.8* Hct-35.1* MCV-88 MCH-31.9 MCHC-36.3* RDW-14.7 Plt Ct-151 [2182-5-3] 07:55AM BLOOD Plt Ct-151 [2182-5-4] 07:18AM BLOOD UreaN-27* Creat-1.1 K-4.1 Brief Hospital Course: Mr. [Known lastname 19816] was a same day admit and on [4-29] he was taken to the operating room where he underwent a Coronary Artery Bypass Graft x 4. please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he was started on diuretics and beta blockers and transferred to the telemetry floor. Also on this day his chest tubes were removed. Epicardial pacing wires were removed on post-op day three. He slowly recovered while receiving physical therapy for strength and mobility. On post-op day 5 he appeared to be doing well and was discharged home with VNA services and the appropriate follow-up appointments. Medications on Admission: ATORVASTATIN 40', BUPROPION 300', FINASTERIDE 5', LISINOPRIL-HCTZ 20mg-12.5mg qhs, NIACIN 1,000', TAMSULOSIN 0.4', TIOTROPIUM BROMIDE 18 mcg qam, ASPIRIN 81', GLUCOSAMINE-CHONDROITIN, MVI Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 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. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:2 7. Niacin 500 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). Disp:60 Capsule, Sustained Release(s) Refills:2 8. Bupropion 150 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). Disp:60 Tablet Sustained Release(s) Refills:2 9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:30 Cap(s) Refills:2 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:20 Tablet(s) Refills:0 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 10 days. Disp:20 Tab Sust.Rel. Particle/Crystal(s) Refills:0 13. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. Disp:90 Tablet(s) Refills:0 14. Ipratropium Bromide 0.02 % Solution Sig: Two (2) puffs Inhalation Q6H (every 6 hours). Disp:1 MDI Refills:2 15. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital3 6011] Care of [Location (un) 8117] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Arterty Bypass Graft x 4 PMH: Hypertension, Hypercholesterolemia, Borderline Diabetes, Chronic Obstructive Pulmonary Disease, Benign Prostatic Hypertrophy, Depression, History of kidney stones, History of peptic ulcer disease, s/p Tonsillectomy Discharge Condition: Good Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Followup Instructions: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 10862] 6 weeks Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 39975] 4 weeks Dr. [Last Name (STitle) 914] 2 weeks [Telephone/Fax (1) 170] Completed by:[2182-5-6]	[ "496", "600.00", "414.04", "272.0", "250.00", "401.9", "414.01", "411.1", "V13.01", "V12.71" ]	icd9cm	[ [ [] ] ]	[ "39.63", "36.15", "39.61", "36.13" ]	icd9pcs	[ [ [] ] ]	6511, 6595	3445, 4262	339, 428	6920, 6926	1153, 2359	7239, 7528	904, 939		4500, 6488	2399, 2424	6616, 6899		4288, 4477			6950, 7216									954, 1134																								280, 301	2456, 3422									456, 568															590, 806	822, 888
28,335	100,694	31494	Discharge summary	report	Admission Date: [2152-8-27] Discharge Date: [2152-8-30] Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[First Name3 (LF) 106] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: 1. cardiac catheterization and stenting History of Present Illness: 88F without previous cardiac history p/w acute onset of light-headedness and SOB. Pt was with son at home eating dinner. At roughly 8pm she got up to go to the bathroom. On returning from the bathroom, the son noted that she was SOB and lightheaded so that she had to sit down. The pt was less alert than usual and so the son [Name (NI) 47658] her flat on the ground and called 911. She was diaphoretic though never mentioned any chest pain, The ambulance arrived and found her hypotensive by report and she was taken to the ED. Past Medical History: Arthritis gallstones ?spastic bladder Social History: Lives with son for the summer in [Name (NI) 86]. Normally lives with another son in [State 5887]. She is a retired seamstress. Smoked for 5-10 years, though quit over 50 years ago. Drinks wine with dinner. Needs cane to walk, feeds, dresses self, but doesn't cook for self. Family History: Mother died in 80s after a hip frx Father: died in 50s from coal miner's lung Physical Exam: VS: T 99.8, BP 150/66, HR 93, RR 19, O2 100% on 4L Gen: Elderly female in NAD, resp or otherwise. Oriented x1. 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 8cm. CV: PMI located in 5th intercostal space, midclavicular line. SEM RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Bibasilar crackles Abd: soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No L femoral bruit, R leg in brace Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Leg brace, 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: [2152-8-27] 09:10PM WBC-14.4* RBC-3.19* HGB-9.3* HCT-29.4* MCV-92 MCH-29.3 MCHC-31.7 RDW-14.8 [2152-8-27] 09:10PM NEUTS-77.8* LYMPHS-17.0* MONOS-4.3 EOS-0.7 BASOS-0.2 [2152-8-27] 09:10PM PLT COUNT-217 [2152-8-27] 09:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2152-8-27] 09:10PM ALBUMIN-3.6 CALCIUM-8.2* PHOSPHATE-2.7 MAGNESIUM-2.7* [2152-8-27] 09:10PM CK-MB-27* MB INDX-4.9 [2152-8-27] 09:10PM cTropnT-6.34* [2152-8-27] 09:10PM LIPASE-41 [2152-8-27] 09:10PM ALT(SGPT)-28 AST(SGOT)-93* CK(CPK)-548* ALK PHOS-109 AMYLASE-45 TOT BILI-0.3 [2152-8-27] 09:10PM GLUCOSE-198* UREA N-40* CREAT-1.6* SODIUM-140 POTASSIUM-5.2* CHLORIDE-106 TOTAL CO2-19* ANION GAP-20 [2152-8-27] 09:46PM TYPE-ART PO2-145* PCO2-27* PH-7.44 TOTAL CO2-19* BASE XS--3 INTUBATED-NOT INTUBA [2152-8-27] 09:46PM LACTATE-2.7* K+-4.3 CL--113* LIPID/CHOLESTEROL Cholest 117 Triglyc 59 HDL 51 CHOL/HD 2.3 LDLcalc 54 [8-30] B12 396, Folate 17.3, Iron 37, calcTIBC 285, Ferritin 119, TRF 219 Retic 1.1% . EKG [8-27]: complete heart block with junctional escape at [Street Address(2) 74118] elevations II, III, aVF, LAD, PRWP, PR . Cardiac Cath [8-27] 1. Coronary angiography in this right dominant system demonstrated single vessel disease. The LMCA and LCx had no angiographically apparent flow limiting epicardial disease. The LAD had minimal disease. The mid-RCA had an 80% lesion and mid/distal total occlusion. 2. Resting hemodynamics revealed elevated right sided filling pressures with an RVEDP of 17 mmHg and PCWP = 16 mm Hg consistent with RV infarct physiology. There was moderate pulmonary systolic hypertension with a PASP of 46 mmHg. There was mild systemic arterial systolic hypertension with an SBP of 148 mmHg. 3. Successful stenting of the distal and mid RCA lesions with 2.5 X 28 mm Minivision and 3.0 X 16 mm Liberte bare metal stents with no residual stenosis (see PTCA comments for detail). 4. Successful treatment of inferior MI with thrombectomy and primary PTCA. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Acute inferior myocardial infarction, managed by acute export thrombectomy and dilation and stenting of mid and distal RCA lesions. 3. Moderate pulmonary artery hypertension and Right ventricular dysfunction. 4. Mild systemic arterial hypertension. 5. Successful stenting of the distal and mid RCA with bare metal stents. . TTE [8-29] The left atrium is normal in size. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with focal akinesis of the basal inferior and inferolateral walls and hypokinesis of the basal to mid inferior walls. The remaining segments contract normally (LVEF = 50 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The right ventricular cavity is mildly dilated. There is moderate global right ventricular free wall hypokinesis with apical dyskinesis. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Severe (4+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Regional left and right ventricular dysfunction consistent with inferior/inferolateral myocardial infarction with right ventricular involvement. Severe mitral regurgitation. Borderline elevated pulmonary artery systolic pressures. . CXR [8-30]: IMPRESSION: No fluid overload or heart failure. No acute cardiopulmonary disease. Brief Hospital Course: 1. STEMI: Symptoms started at roughly 8pm and pt arrived in the ED at 8:30pm. In the ED, her vitals were: Pulse 50, BP 99/65, Respiratory Rate 22, O2 saturation 97% on 4L nasal canula. Initial ECG showed ST elevations inferiorly and complete heart block with a junctional escape. Pt was given asa, plavix 600mg x1, heparin gtt, integrilin and transferred to the cath lab. At cath, she was found to have a 80% mid total occlusion of the RCA which was opened and treated with a bare metal stent. There was no hemodynamic instability, though pacing was transiently required during the cath for heart rate in 40s. The patient was admitted to CCU for overnight monitoring, arriving in stable condition with pulse in 90s BP 120/80. In the CCU, she had an uneventful course with no further ischemic symptoms or evidence of heart block, and was discharged on aspirin, clopidogrel, atorvastatin, metoprolol, lasix, and lisinopril. She will follow up her primary care physician and cardiologist upon her return to [State 5887] in two weeks. Her lipid panel should be repeated as an outpatient. . 2. Mitral Regurgitation: The patient's [8-29] echocardiogram was notable for severe (4+) mitral regurgitation. She should have a cardiac MRI in [3-31] weeks for further evaluation, with consideration for possible valve repair. . 3. Renal insufficiency: Per the patient's primary care physician, [Name10 (NameIs) ] last recorded creatinine was 1.0 on 7/[2149]. Her creatinine was somewhat elevated from this at 1.6 on admission, and trended back down following rehydration. She will need a repeat creatinine and potassium measurement as she has started an ACE inhibitor in hospital. . 4. Anemia: The patient was found to have a normocytic anemia at admission with hematocrit nadir of 23 in hospital, and consequently was transfused 2 units of PRBCs She did not have any gross GI bleeding, but did have some heme positive stools. She denies ever having a colonoscopy. Her anemia should be worked up further as an outpatient. Her iron studies, folate and B12 levels were normal when checked [8-30]. Chronic renal insufficiency may be a contributing factor to her anemia, although low level GI bleeding should be excluded. . 5. Health maintenance The patient received the pneumovax vaccine prior to discharge Medications on Admission: detrol Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 7. Detrol Oral Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: 1. STEMI 2. complete heart block, resolved Discharge Condition: good Discharge Instructions: You came to the hospital with shortness of breath. Your symptoms were due to a heart attack. You had a stent placed in one of the arteries supplying the heart. You were started on some new medicines to protect your heart. It is very important that you do not stop any of these medicines without first talking to a physician. Please call your doctor and seek medical attention at once if you develop: recurrent shortness of breath, chest discomfort, dizziness or faintness, abdominal pain, black or bloody stools, or other symptoms that worry you Followup Instructions: Please follow up with your primary care doctor Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 74119] at [Telephone/Fax (1) 74120] on Monday [9-18] at 1:30pm. You will also need to follow up with cardiology [2157-9-20]:45pm with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 74121] Heartcare Group ([Location 74122], PA) at [Telephone/Fax (1) 74123**].	[ "414.01", "585.9", "584.9", "410.41", "426.0", "285.9", "424.0", "428.0" ]	icd9cm	[ [ [] ] ]	[ "88.56", "00.46", "99.20", "37.23", "00.66", "36.06", "99.04", "88.52", "00.40" ]	icd9pcs	[ [ [] ] ]	9012, 9070	5935, 8253	262, 304	9157, 9164	2153, 4230	9762, 10178	1242, 1321		8310, 8989		9091, 9136		8279, 8287		4247, 5912	9188, 9739									1336, 2134																								203, 224										332, 866															888, 927	943, 1226
14,061	128,603	3079	Discharge summary	report	Admission Date: [2118-4-23] Discharge Date: [2118-6-8] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 492] Chief Complaint: sepsis Major Surgical or Invasive Procedure: R subclavian line placement History of Present Illness: R3 MICU GREEN ADMISSION NOTE . This is an 87 year old male with with a significant hx for CAD, CABG, DM II and recent R bka on [2118-4-14] who presented from [Hospital 100] Rehab today with increased lethargy. At [Hospital 100] Rehab, the patient's BP was 82/52. His HR ranged from 120-150. His outside labs were significant for a wbc of 22.7k, troponin I 0.05. He received 1.5 L of fluid and was transfered to [Hospital1 18]. . In the ED, the patient vitals were as follows T96.8 HR 92 BP 84/57. Despite 3-4L of fluids the patient remained HD unstable. He was started on levophed with good effect, sbp >100. CVP transduced to 13-15. On CXR there was suggestion of R perihilar infiltrate. He had a PICC line in place. Removal of the bandage revealed some pus. Cultures were not drawn from the line due to an inability to draw back. It was however sent for culture. UA was contaminated. He received Vancomycin and CTX. . Of note in the ED, it was difficult to obtain central access. A RIJ was attempted X 3, with one attempt puncturing the carotid. A right subclavian was obtained. CXR confirmed line placement. . . Past Medical History: Cardiac Risk Factors: (+)Diabetes, (+)Dyslipidemia, (+)Hypertension . Cardiac History: -CABG (4-vessel) in [2106]. -->LIMA to LAD -->SVG to D2 with jump graft to OM -->SVG to RCA . -Percutaneous coronary intervention: [2116-6-30]: MiniVision bare metal stent in LAD [2116-8-25]: PTCA of the 90% 1st Diagonal artery with a 2.0x12mm Voyager balloon [2116-9-10]: Angioplasty of the LAD [2116-9-11]: MicroDriver bare metal stent to mid LAD [2117-1-18]: Cypher drug eluting stent to proximal LAD [2117-9-27]: 3-vessel disease with patent prior stents . Anatomy as of [2116-9-27]: Proximal RCA: 100% occluded LMCA: patent without disease Proximal LAD: normal LAD: patent with open prior stents LCx: 100% stenosis SVBG #1: patent LIMA: patent . Other Past History: 1. Hypertension 2. Hyperlipidemia 3. Diabetes mellitus, diet-controlled 4. Peripheral [Date Range 1106] disease 5. SVT 6. Congestive heart failure , EF 35% on cardiac cath ([9-15]) 7. Prostate CA (treated w/ Lupron injections, seen by Dr. [Last Name (STitle) ] 8. Dementia, likely Alzheimers Cardiac Risk Factors: (+)Diabetes, (+)Dyslipidemia, (+)Hypertension . Cardiac History: -CABG (4-vessel) in [2106]. -->LIMA to LAD -->SVG to D2 with jump graft to OM -->SVG to RCA . -Percutaneous coronary intervention: [2116-6-30]: MiniVision bare metal stent in LAD [2116-8-25]: PTCA of the 90% 1st Diagonal artery with a 2.0x12mm Voyager balloon [2116-9-10]: Angioplasty of the LAD [2116-9-11]: MicroDriver bare metal stent to mid LAD [2117-1-18]: Cypher drug eluting stent to proximal LAD [2117-9-27]: 3-vessel disease with patent prior stents . Anatomy as of [2116-9-27]: Proximal RCA: 100% occluded LMCA: patent without disease Proximal LAD: normal LAD: patent with open prior stents LCx: 100% stenosis SVBG #1: patent LIMA: patent . Other Past History: 1. Hypertension 2. Hyperlipidemia 3. Diabetes mellitus, diet-controlled 4. Peripheral [Date Range 1106] disease 5. SVT 6. Congestive heart failure , EF 35% on cardiac cath ([9-15]) 7. Prostate CA (treated w/ Lupron injections, seen by Dr. [Last Name (STitle) ] 8. Dementia, likely Alzheimers Social History: Per prior notes, former [Company 2318] engineer, works as [Doctor Last Name ] [Hospital1 14630]. He lives with his wife and oldest son. [Name (NI) ] has never smoked tobacco or used illicit substances. He denies current EtOH. Family History: Per pt, there is no family history of CAD or sudden death. Physical Exam: . Physical Exam: T: 97.9 BP: 98/60 P: 82 RR: 23 O2 sats: 100% on 2l Gen: African American male in NAD lying in bed, complaining that he is cold HEENT: MMM dry, OP clear, JVP CV: nl rate, S1S2, no gmr Resp: CTA b/l, no RRW Abd: +BS, no guarding, no rebound tenderness Back: no spinal tenderness,no CVA tenderness Ext: R BKA, staples c/d/i, no no erythema or warmth noted, L lower extremity cold, pulses dopplerable Neuro: CN: II-XII grossly intact Strength: patient not willing to participate Reflexes: patient not willing to participate . Pertinent Results: [2118-4-23] 04:35PM WBC-25.4# RBC-3.14 HGB-8.3* HCT-27.3* MCV-87 MCH-26.6* MCHC-30.6* RDW-18.7* [2118-4-23] 04:35PM CALCIUM-7.7* PHOSPHATE-2.9 MAGNESIUM-1.4* [2118-4-23] 04:35PM CK-MB-9 [2118-4-23] 04:35PM cTropnT-0.25* [2118-4-23] 08:10PM LACTATE-1.3 [2118-4-23] 10:57PM CORTISOL-25.4* MICRO Premlim cx data Blood: gram negative rods Brief Hospital Course: Mr. [Known lastname 4427] is an 87 year old male with HTN, CAD s/p CABG, DM with prolonged hospital stay complicated by klebsiella sepsis seconary to line infection, cardiogenic shock requiring pressors and intubation, L IJ thrombus on heparin, retransferred to ICU for hypotension requiring intermittent NE gtt, re-intubated on [6-3]. He was changed to CMO status on [6-7] with the full knowledge and consent of his family and he was terminally extubated. He expired a few hours later at 02:10 in the morning. Medications on Admission: 1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [Hospital1 ] (2 times a day). 14. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO three times a day: prn. Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: patient expired Discharge Condition: patient expired Discharge Instructions: patient expired Followup Instructions: patient expired [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [Doctor First Name 494]	[ "414.00", "518.81", "401.9", "995.92", "584.9", "785.52", "507.0", "512.8", "V45.82", "427.89", "453.8", "250.00", "038.49", "V49.75", "999.31", "427.32", "785.51" ]	icd9cm	[ [ [] ] ]	[ "33.23", "38.93", "96.6", "96.04", "96.72" ]	icd9pcs	[ [ [] ] ]	6880, 6889	5020, 5548	273, 302	6948, 6965	4621, 4997	7029, 7159	3981, 4041		6840, 6857		6910, 6927		5574, 6817			6989, 7006									4073, 4602																								227, 235										330, 1474															1496, 3703	3719, 3965
60,773	188,086	42859	Discharge summary	report	[ ] Date: [2109-2-20] Discharge Date: [2109-3-1] Date of Birth: [2050-5-18] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 10593] Chief Complaint: tachycardia, low hct, guaiac + stool Major Surgical or Invasive Procedure: none History of Present Illness: EAST HOSPITAL MEDICINE ATTENDING [First Name3 (LF) ] NOTE Date: [2110-1-21] Time: 23:20 The patient is a Ms. [Known lastname 1007] is a 58 year old F with Multiple Sclerosis with recent discharge for UTI, altered mental status, bilateral DVT's, and new diagnosis of ovarian cancer, who presents with tachycardia and drop in hemoglobin/hematocrit and guaiac positive stools, but not gross blood. Pt has no complaints but is only AOx1. Denies fevers, chills, nausea, vomiting, abd pain, back pain, black or bloody stool. Pt recently admitted and started on lovenox for DVT and was discharged yesterday. Had 5pt Hct drop while in house in the setting of diagnostic paracentesis to eval for malignant ascites, transfused 1U PRBC with good response (28->23->1 pRBCs->28). Has IVC filter in place. In the ED inital vitals were, 98.5 135 133/84 16 97% RA. Exam was notable for guaiac positive dark brown stool, no gross blood. Labs were notable for Hct 22.3 from baseline Hct 27 in the last month, and 37 in Atrius in 1/[2108]. NGL was attempted but patient was unable to tolerate it. GI consulted and recommended 2 u pRBCs and pantoprazole 40mg [Hospital1 ]. Troponins were negative x1. Cr 1.2 (baseline 1.2-1.3). UA showed RBC 64, WBC 37, Bacteria few, Leuk mod, Nitrite negative. CXR (prelim) shows atelectasis, no acute process. ECG showed sinus tachycardia. She was given CTX x1 for UTI, 1 unit PRBC's, IV pantoprazole. CT abd/pelvis showed new L paraspinal muscle hematoma likely [3-14] Lovenox, no active extravasation, IVC filter w/ unchanged R common/ext iliac clot. No evidence of intraabdominal bleed [3-14] recent paracentesis. Patient was admitted to the ICU for tachycardia and concern for active bleed. VS prior to transfer 99.4 148/90 133 99 2lnc. On arrival to the ICU, VS: T: 100.0 BP: 134/93 P: 128 R: 20 O2: 96% ra. Patient lying comfortable in bed, without complaints. Denies pain, admits to feeling tired. Unable to give a history as she is A&Ox1. On floor, she is reports no pain or problems. She only endorses feeling thirsty and hungry. Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies visual changes, headache, dizziness, sinus tenderness, neck stiffness, rhinorrhea, congestion, sore throat or dysphagia. Denies chest pain, palpitations, orthopnea, dyspnea on exertion. Denies shortness of breath, cough or wheezes. Denies nausea, vomiting, heartburn, diarrhea, constipation, BRBPR, melena, or abdominal pain. No dysuria, urinary frequency. Denies arthralgias or myalgias. Denies rashes. No increasing lower extremity swelling. No numbness/tingling or muscle weakness in extremities. No feelings of depression or anxiety. All other review of systems negative. Past Medical History: - ovarian cancer - recently diagnosed [2-/2109] - Osteoporosis - multiple sclerosis, wheelchair bound with indwelling Foley, - hyperlipidemia - frequent urinary tract infections - myelopathy - chronic pain syndrome Social History: She lives in a skilled nursing facility. A brother is healthcare proxy. She has never smoked. She does not drink alcohol. Family History: Her mother had multiple sclerosis and died at age 72 years of MI. Her father had hypertension, depression and died of pacreatic cancer at age 62 years. Physical Exam: VS: 99.9 105 140/87 18 100% 2L; pain 0/10 GEN: No apparent distress HEENT: no trauma, pupils round and reactive to light and accommodation, no LAD, oropharynx clear, no exudates CV: regular rate and rhythm, no murmurs/gallops/rubs PULM: Clear to auscultation bilaterally, no rales/crackles/rhonchi GI: soft, non-tender, non-distended; no guarding/rebound EXT: Anasarca; no clubbing/cyanosis; 2+ distal pulses; peripheral IV present NEURO: Alert and oriented to person, place and situation; CN II-XII grossly intact DERM: no lesions appreciated Pertinent Results: LABS: On [Year (4 digits) ]: [2109-2-20] 09:00PM BLOOD WBC-10.3 RBC-2.35* Hgb-7.3* Hct-22.3* MCV-95 MCH-31.0 MCHC-32.6 RDW-14.3 Plt Ct-501* [2109-2-20] 09:00PM BLOOD Neuts-86.1* Lymphs-9.1* Monos-3.7 Eos-0.6 Baso-0.4 [2109-2-20] 09:14PM BLOOD PT-12.6* PTT-28.2 INR(PT)-1.2* [2109-2-20] 09:00PM BLOOD Glucose-97 UreaN-34* Creat-1.2* Na-135 K-5.1 Cl-102 HCO3-23 AnGap-15 [2109-2-20] 09:00PM BLOOD CK(CPK)-15* [2109-2-20] 09:00PM BLOOD cTropnT-<0.01 [2109-2-19] 01:41PM BLOOD Hgb-8.5* calcHCT-26 [2109-2-21] 5:31PM HCT 31.0 [2109-2-21] 4:47PM UA: Source: Catheter, Color Yellow, Appear Clear, SpecGr 1.024, pH 5.0, Urobil Neg, Bili Neg, Leuk Mod, Bld Sm, Nitr Neg, Prot Tr, Glu Neg, Ket Neg, RBC 7, WBC 53, Bact None, Yeast Rare, Epi 1 Mucous: Rare, NonsqEp: <1 [2109-2-21] 11:38AM HCT 29.0 [2109-2-21] 05:50AM Na 137, Cl 105, BUN 31, GLU 90, AGap=16, K 5.0, CO2 21, sCr 1.1 Ca: 7.2 Mg: 1.7 P: 3.3 Glu 94, HCT 30.7 ∆, HGB 10.3, Ca [07].4 ∆, PLT 354 PT: 12.7 PTT: 26.4 INR: 1.2 CHEST (PORTABLE AP): Left PICC terminates at the superior cavoatrial junction. Lung volumes are low, there is continued left lower lobe opacity with partial silhouetting of the hemidiaphragm, corresponding to atelectasis on prior CT. Small left pleural effusion is also present. The right lung is clear. Heart size is normal. Old healed right anterior second through fourth rib deformities. IMPRESSION: Unchanged left lower lobe atelectasis and small effusion. The study and the report were reviewed by the staff radiologist. CTA ABD & PELVIS: FINDINGS: There has been slight increase in moderate left and small right simple pleural effusions, with associated compressive atelectasis. The heart is normal in size, with physiologic pericardial fluid. ABDOMEN: There has been interval decrease in moderate ascites post-paracentesis. Subcutaneous gas is noted in the right lower quadrant at the site of paracentesis access, and tracks along the preperitoneal space. Moderate ascites is present throughout the abdomen. There is diffuse omental caking, with lobulated enhancing masses encasing the entire upper peritoneum, particularly . Soft tissue implants are also noted along the right hepatic lobe extending into [Location (un) 6813] pouch and along the right kidney and paracolic gutter, right anterior omentum, periportal space tracking along the falciform ligament, gastrohepatic ligament, and splenic hilum tracking inferiorly along the left paracolic gutter. There is centralization of bowel loops and viscera, compatible with malignant ascites. The liver enhances homogeneously, without focal lesions. Gallbladder is partially collapsed, with mild wall edema secondary to third spacing. The pancreas is atrophic, but enhances normally. There is no intra- or extra-hepatic biliary ductal dilation. Spleen is normal in size. The adrenals are normal. The kidneys are atrophic, with cortical thinning and lobulation suggesting prior ischemic or infectious injury, as well as multiple dystrophic calcifications. Moderate hydronephrosis and proximal hydroureter persists, tapering gradually into the pelvis without evidence of obstructing stones. The stomach is normal. Mild wall edema is noted in the first and second portions of the duodenum, likely due to third spacing. The distal small bowel is unremarkable. PELVIS: Again seen is a large pelvic mass measuring 14.7 cm AP x 12.7 cm TV x 12.5 cm SI. This is a markedly heterogeneous appearance with irregular enhancement due to mixed solid and cystic components, internal septations, and coarse internal calcification. The cecum is anteriorly folded. A 1-cm pedunculated lesion along the medial wall of the ascending colon (600B:33) may represent an epiploic appendage. Mild wall edema is noted in the hepatic flexure, likely due to third spacing. Transverse and descending colon are unremarkable. The proximal sigmoid colon is encased within the pelvic mass and collapsed. However, there is partial reconstitution of the mid-sigmoid, as well as a patulous rectum with intact oral contrast passage, excluding physiologic obstruction. The uterus is contained within the right inferior aspect of the mass, and appears distorted, with retained fluid in the endometrial canal. The bladder and distal ureters are compressed inferiorly. A Foley catheter is present, with balloon inflated at the bladder dome, and tip kinking the bladder anterosuperiorly. There is mild lumbar dextroscoliosis, with multilevel degenerative changes. Transitional lumbosacral anatomy is noted at L5-S1 on the left. Unchanged L2 compression fracture demonstrates 50% loss of anterior height. Bilateral pars defects are noted at L4-L5, with grade [2-11] anterolisthesis and near complete loss of disc space. There is minimal retrolisthesis at L5-S1. Marked deformity of the sacrum, which is deviated to the left, with apparent post-traumatic deformity at S1-S2. Pelvic girdle is also dystrophic. Old healed fractures of the bilateral inferior pubic rami. There has been interval development of a 7.1 cm TV x 5 cm AP x 9.2 cm SI intramuscular hematoma in the left paraspinal muscle, spanning the L1 through L4 levels. This demonstrates mixed hyper- and hypodense components, compatible with acute-on-subacute hemorrhage. There is no evidence of retroperitoneal extension. Diffuse anasarca is present. CT ARTERIOGRAM: There is no evidence of active arterial extravasation. Note is made of superior compression and kinking of the celiac artery by an anomalous diaphragmatic crus, suggestive of median arcuate ligament syndrome in the correct clinical setting. Superior/inferior mesenteric artery origins are widely patent. Note is made of aberrant origin of the splenic artery from the superior mesenteric artery. CT VENOGRAM: There is no evidence of venous extravasation. The portal, splenic, superior and inferior mesenteric, and hepatic veins are widely patent. Retrievable IVC filter is present, with tip at the level of the renal artery takeoffs. Again noted is near-occlusive thrombus involving the distal right common and proximal right external iliac veins. Left common femoral and superficial femoral venous clots have at least partially resolved. IMPRESSION: 1. New left paraspinal hematoma, without active extravasation. 2. Decrease in malignant ascites post-paracentesis. 3. Diffuse metastatic omental caking and peritoneal seeding. 4. Large pelvic mass, with distal ureteral obstruction and encasement of the sigmoid colon and uterus. 5. Deep venous thrombosis, with IVC filter in place. Brief Hospital Course: Ms. [Known lastname 1007] is a 58 year old F with Multiple Sclerosis with recent discharge for UTI, altered mental status, bilateral DVT's on lovenox, and new diagnosis of ovarian cancer, who presents with tachycardia, 5 point hematocrit drop, guaiac positive stools, and recent paracentesis complicated with bleeding. # Anemia: On [Known lastname ] hct 22.3, down from 27 on discharge on [2109-2-18]. On lovenox for DVTs, so has increased risk of bleeding. Likely primarily due to new left paraspinal muscle hematoma seen on CT (7.1 cm TV x 5 cm AP x 9.2 cm SI, spanning the L1 through L4 levels). GI was consulted - felt that the acute blood loss was more likely related to paraspinal hematoma rather than GI bleed. Nonetheless, EGD was considered, but patient declined. # Tachycardia: She was also tachycardic during last [Date Range ], attributed at that time to hypermetabolic state and metoprolol was uptitrated from XL 75mg daily to 37.5mg TID. [Month (only) 116] also be due worsened by acute blood loss (see above) and DVT. Restarted metoprolol at slightly lower dose (25mg TID) to avoid rebound tachycardia. Her HR decreased with blood transfusion and IV fluids to 90s-100s. Metoprolol was held briefly for concern of further GI bleeding, however HR increased to 120s without further evidence of bleeding so metoprolol was restarted at 25mg TID just prior to trasnfer to medicine floor. HR improved since adding metoprolol. Later, she was unable to take po metoprolol, so this was switched to iv metoprolol, initially 2.5 mg iv q6h, then up to 7.5 mg iv q6h. # DVT: She has an IVC filter placed and has been on Lovenox since her last [Month (only) ]. We held her lovenox on [Month (only) ], given concern for acute bleed. Heparin ggt held in ICU given concern for bleed. V/Q scan from recent [Month (only) ] here showed low probability for PE. Restarted iv heparin when Hct stabilized. Switched to Lovenox 50 mg sc bid on [2-25] (she had been on 60 mg sc bid at the time of last discharge). Increased to 60 mg sc bid when Hct remained stable. # UTI: Multiple previous UTI's due to chronic indwelling foley. Last hospitalization several days prior to [Month/Year (2) ] showed urine culture of ampicillin sensitive enterococcus. ?Reportedly needs lifelong Ampicillin prophylaxis, so she was continued on this on [Month/Year (2) ]. Urine cultures here grew ~5000 yeast. Two week course of ampicillin was completed on [2-24]. . # Ovarian Cancer, probable: Large pelvic mass visualized again. She was seen by Atrius Oncology here. . # Multiple Sclerosis: Not on medications currently. On provigil and baclofen at home. Restarted modafenil. . # Encephalopathy: Her baseline is A&Ox3 and able to engage in conversation, though occasionally confused. Was somewhat encephalopathic on her last [Month/Year (2) ] as well, however this improved upon treatment of her UTI. Has had extensive work up recently at [Hospital3 ] (LP, MRI brain, etc) that did not reveal any significant abnormalities. According to her brother, her mental status has waxed and waned considerably in the last few weeks. The weekend of [2-23]-15, she became more encephalopathic - she was awake and responded to questions, but in a nonsensical manner, repeating syllables, and unable to state her full name, though she did follow some instructions. #END OF LIFE CARE: Over the last few days of her hospitalization, Ms. [Known lastname 1007] had persistent encephalopathy, and became less interactive. Infectious work-up was unrevealing. There was no clear reversible cause of her encephalopathy. She was unable to take her po meds, and her po intake of food was quite limited. She had anasarca. TPN was initiated. Neurology was consulted - they thought that her encephalopathy was most likely toxic-metabolic, though paraneoplastic encephalopathy or non-convulsive seizures could also be playing a role. Lumbar puncture was not done, as she had had a complication (hematoma) from an LP during a previous hospitalization, and findings of LP were very unlikely to change management. Bedside EEG was done -showed generalized encephalopathy, but no seizure activity. Oncology, Palliative Care, and Neurology joined in meetings with the patient's brother, [Name (NI) ] [Name (NI) 1007]. Given the extent of her cancer and her poor functional status, she was not a candidate for surgery nor for chemotherapy. In a meeting on [2-28], given Ms. [Known lastname ] declining status, new signs of discomfort (groaning, poor responsiveness), no identifiable reversible cause of encephalopathy, and overall disease burden, it was decided (with [First Name4 (NamePattern1) ] [Known lastname 1007] and multidisciplinary team) to shift to comfort-focused care. She expired on [2109-3-1] at 4:12pm. Her brother, [Name (NI) ], was present. Medications on [Name (NI) ]: 1. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 4. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for yeast infection. 5. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. modafinil 100 mg Tablet Sig: Two (2) Tablet PO qday (). 7. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 8. ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours). 9. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for fever or pain. 10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 11. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 12. Miralax 17 gram Powder in Packet Sig: One (1) PO once a day. 13. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. 14. ibandronate 150 mg Tablet Sig: One (1) Tablet PO once a month. 15. baclofen 10 mg Tablet Sig: One (1) Tablet PO four times a day. 16. multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: ovarian cancer, advanced, probable multiple sclerosis Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a	[ "272.4", "518.0", "584.9", "V66.7", "V49.86", "197.6", "596.4", "E879.6", "733.00", "338.29", "349.82", "785.0", "996.64", "261", "285.1", "V58.61", "599.0", "183.0", "729.92", "453.41", "340" ]	icd9cm	[ [ [] ] ]	[ "99.15" ]	icd9pcs	[ [ [] ] ]	17130, 17139	10897, 17078	340, 347	17237, 17247	4280, 10874	17299, 17305	3545, 3699		17101, 17107		17160, 17216					17271, 17276									3714, 4261																			2483, 3147					263, 302										375, 2464															3169, 3390	3406, 3529
49,276	121,630	36857	Discharge summary	report	Admission Date: [2134-5-31] Discharge Date: [2134-6-19] Date of Birth: [2058-5-20] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 7651] Chief Complaint: R sided neglect Major Surgical or Invasive Procedure: PEG tube History of Present Illness: As Per Neurology H+P: Patient is a 76 yo RHW with unclear PMH other than HTN and hx of heavy EtOH use per sister-in-law who last saw her 3 years ago. Per medical records from [Hospital3 ] from where she was transferred, she lives alone and is looked in on by neighbors. She was last seen at baseline several days priort to admission, gardening in the yard. A neighbor noticed that she has not been seen for a few days went to check in on her and found her down. She was supine but unclear whether in bed or on the floor and was nonverbal. At this time she was taken to [Hospital3 ]. She was found to be in Afib with RVR at [Hospital1 ] and was started on Diltiazem gtt and had a head CT that showed no hemorrhage or fracture. Then, she was transferred here for further evaluation and care. Her next of [Doctor First Name ] is [First Name4 (NamePattern1) 17] [Known lastname 16471], her sister-in-law who reports that she does not know anything because she last saw her > 3 years ago and the patient has never shown up for family events despite invitations. She does report that the patient was a heavy drinker and was still drinking heavily 3 years ago. Review of systems was not able to be obtained due to the patient's dysphasia. Past Medical History: 1. HTN 2. EtOH abuse Social History: Lives alone - no family or children. Next of [Doctor First Name ] is [First Name4 (NamePattern1) 17] [Known lastname 16471] who is her sister-in-law ([Telephone/Fax (1) 83240]) and code status unknown hence presumed full. Heavy drinker per sister-in-law and retired [Name (NI) ] employee. Family History: Father died of MI at age 63 and brother died of kidney failure at age 59. Physical Exam: As Per NEUROLOGY ADMIT NOTE: BP 120/70 HR 130 RR 18 O2Sat 100% RA Gen: Lying in bed, NAD though very disheveled and poor grooming. HEENT: NC/AT, moist oral mucosa CV: Irregularly irregular, no murmurs/gallops/rubs Abd: +BS, soft, nontender Ext: No edema; trace dorsalis pedis palpable bilaterally. Pitting edema on RUE only. Neurologic examination: Mental status: Awake and alert - oriented to self but only response is "okay" to all questions. No repetition. Does not follow commands except for opening and closing eyes - no appendicular commands or sticking tongue out. Cranial Nerves: Pupils reactive and equal. Does track across midline but less blinking to threat on R side. R facial droop. No gag but palate elevates evenly. Motor: Diffusely decreased bulk. Spontaneous movements on L - appers full strength although individual muscle group testing not possible. Does withdraw to pain on RLE and when lifting the RUE in front of her eyes, no drift. Sensation: Appears intact to noxious stimuli and LT in all extremities. Reflexes: +2 and symmetric for UEs but trace on L patellar vs. 2 for R patellar. Toes upgoing bilaterally Pertinent Results: [2134-5-31] 11:45AM GLUCOSE-87 UREA N-7 CREAT-0.4 SODIUM-137 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-20* ANION GAP-16 [2134-5-31] 11:45AM CALCIUM-8.5 PHOSPHATE-2.9 MAGNESIUM-1.7 [2134-5-31] 11:45AM WBC-11.6* RBC-3.15* HGB-11.6* HCT-34.5* MCV-110* MCH-36.8* MCHC-33.6 RDW-16.8* [2134-5-31] 01:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2134-5-31] 01:00AM URINE RBC-[2-4]* WBC-[10-22]* BACTERIA-FEW YEAST-NONE EPI-0-2 [2134-5-31] 11:45AM %HbA1c-4.7* [2134-5-31] 02:34AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2134-5-31] 01:19AM LACTATE-1.7 [2134-5-31] 01:00AM CK(CPK)-24* [2134-5-31] 01:00AM cTropnT-<0.01 [2134-5-31] 01:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2134-5-31] 01:00AM PT-13.5* PTT-22.4 INR(PT)-1.2* NCHCT: Appears to have extensive small vessel ischemic changes and possibly subacute/chronic L putamen infarct. [Numeric Identifier 77635] G TUBE PLACMENT [6-15] Uncomplicated placement of 12 French Wills-[Doctor Last Name 12433] percutaneous gastrostomy tube. The tube may be used in 24 hours, if the patient is not experiencing pain. The T-fasteners will fall out on their own in approximately 6 weeks. The patient can return for routine tube exchange in three months, or earlier for removal if no longer needed. MRI/MRA Brain [6-1] 1. Extensive evolving acute infarction, predominantly involving the anterior cerebral, deep middle cerebral, and superior middle cerebral arterial territories. Small foci of infarction in the posterior/inferior middle cerebral arterial territory. 2. Extensive chronic small vessel ischemic disease. 3. Normal head MRA. Brief Hospital Course: NEUROLOGY COURSE: 76y RHF with HTN and h/o EtOH use w/ a. fib w/ RVR, right neglect, right weakness and global aphasia of unknown duration. Pt was admitted to neuro ICU team for observation and treatment of A.Fib w/ RVR. Her neurologic exam remained stable. MRI showed Left ACA and MCA stroke. she underwent Stroke work up including echo which did not reveal clot,carotid ultrasound, HbA1C, TSH, fasting lipids were done. Pt found to have UTI on UA and treated with bactrim.Her hospital course was complicated by rapid A fib/ Flutter and was treated with diltiazem and beta blockers per cardiology inputs. Neurologically she did not show much improvement and failed speech, swallow test. she underwent PEG placement. She was later transfered to Cardiology service for control of heart rate. CV-Coronary: Despite heart rates in the 140's and 150's, she has never desaturated and never appeared to be in pain or respiratory distress. She has never had EKG changes consistent with ischemia, and never made cardiac enzymes. CV-PUMP: Echo [2134-6-1] showed The left atrium as mildly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast without maneuvers. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. Mild to moderate ([12-4]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. She has never appeared to be in CHF or otherwise volume overloaded, and her pressures have tolerated high doses of diltiazem, though 90mg qd is likely the max dose her pressures can handle given occasional dips into the high 80s. CV RHYTYM: The patient arrived to the cardiology service on 180 SR Diltiazem with diltiazem drip. She was converted to 90mg Diltiazem q6h. After starting this regimen her HR never exceded 110 BPM, and in fact she remain in Aflutter with a rate of 72. Given that AFlutter is notoriously difficult to rate control, we evaluated her for TEE and D/C cardioversion. However the team felt on examining the patient that she would not be able to cooperate in TEE exam and that it would be traumatic with high liklihood of faillure. Because she never seemed uncomfortable, even with excessively high heart rates we decided to send her to rehab for 4 weeks of anticoagulation and have her return to see Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] to evaluate her for D/C cardioversion at that juncture. We can tolerate HR up to 150 if she has no hemodynamic instability or obvious discomfort with it. - Please continue on 120mg Diltiazem in the morning and 90mg three times a day (regimen will be 120mg/90mg/90mg/90mg every 6 hours). - Pt noted to have episodes of A. fib with RVR into the 140s, after discussion with Cardiology would allow pt to continue at this rate as it usually terminates when she recieves her next dose of Diltiazem. Would refer back to the ED if pt become hemodynamically unstable with systolic pressure less than 90 - Pt will need to follow up with new Cardiologist to assess for possible cardioversion in 4 weeks (she will need to be anticoagulated for this) - Please continue to follow inr every Mon, Wed, Fri to titrate Coumadin dose for a goal inr of [1-5]. UTi: Pt noted to have a mild leukocytosis prior to discharge, pt showed no evidence of fevers or symptoms. A U/A was obtained which showed positive Leukocyte esterase as well as bacteria and WBCs. Pt was started on a 3 day course of Levofloxacin 500mg daily. Urine culture obtained, will call Rehab facility if culture is positive for resistance against Levofloxacin. Nutrition: During hospitalization pt underwent video swallow which showed multiple consistencies of oral barium were administered and passed beyond the oropharynx without evidence of obstruction. However thin liquids were seen to penetrate and were aspirated silently. A cued cough was ineffective. Pt underwent PEG tube placement and was started on tube feeds. - Please continue Fibersource HN Full strength at 45cc/hr, with residual Check q4hrs. Please continue on H20 flush w/ 150 ml every 6 hours. Medications on Admission: None Discharge Medications: 1. Acetaminophen 325 mg Tablet [Date Range ]: Two (2) Tablet PO Q6H (every 6 hours) as needed for T>100.4 or pain. 2. Atorvastatin 20 mg Tablet [Date Range ]: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet [Date Range ]: One (1) Tablet PO DAILY (Daily) as needed for alcohol abuse. 4. Thiamine HCl 100 mg Tablet [Date Range ]: One (1) Tablet PO DAILY (Daily) as needed for alochol abuse. 5. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization [Date Range ]: One (1) Inhalation Q6h () as needed for COPD. 6. Diltiazem HCl 90 mg Tablet [Date Range ]: One (1) Tablet PO QID (4 times a day): Please take with the extra 30mg of Diltiazem in the morning. You will be taking 120mg in the morning and 90mg the other times. 7. Multivitamin Tablet [Date Range ]: One (1) Tablet PO once a day. 8. Warfarin 5 mg Tablet [Date Range ]: One (1) Tablet PO QHS (once a day (at bedtime)). 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 10. Outpatient Lab Work Please have the rehab doctors [Name5 (PTitle) 4169] your PT/INR every Monday, Wednesday, Friday to adjust your Coumadin to a goal INR of [1-5]. 11. Diltiazem HCl 30 mg Tablet [Date Range ]: One (1) Tablet PO qAM: Please take with the 90mg Dilitazem morning dose. 12. Outpatient Lab Work Please have your blood drawn every Monday, Wednesday, Friday to check your INR. The rehab doctors [Name5 (PTitle) ] be [Name5 (PTitle) 460] to titrate your Coumadin level for a goal INR of 2 to 3. 13. Ciprofloxacin 250 mg Tablet [Name5 (PTitle) ]: One (1) Tablet PO Q12H (every 12 hours) for 5 doses. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Left Anterior Cerebra Artery stroke , Medial Coronary Artery Stroke Atrial Flutter/ Fibrillation Hypertension Percutaneous Enteral Gastric Tube Placement Discharge Condition: improved Discharge Instructions: You were admitted to [Hospital3 ] after having a large stroke, that has heavily effected the left side of your brain, and as a result you now have significant weakness on your right side and difficulty speaking. You also developed an irregular and rapid heart beat. You will need to return to the hospital in 4 weeks to have a special procedure done where we shock your heart back into rhythym. You were determined to have a UTI on the last day of your hospitalization. You were started on ciprofloxacin 250mg twice per day for 3 days. We were never able to determine your home meds, however you were started on several new medications in the hospital including: Atorvastatin 20 mg DAILY Diltiazem 90 mg 4 times per day Lansoprazole Oral Disintegrating Tab 30 mg Thiamine 100 mg DAILY Warfarin 5 mg QHS Ciprofloxacin 250mg twice per day for 5 more doses After discussion with the Cardiologist we will tolerate your heart rate in the 140s unless your blood pressure drops below 90 for systolic pressure. If you experience any fevers >101, heart rate >140 with a systolic blood pressure <90 or you have difficulty breathing and are hypoxic. Followup Instructions: Please follow up with DR. [First Name8 (NamePattern2) ] [First Name11 (Name Pattern1) 640] [Last Name (NamePattern4) 3445], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2134-7-7] 1:00 **Please make a follow up appointment with the cardiology attending that saw you here, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] to be evaluated for electric cardioversion. [Telephone/Fax (1) 62]very important! You will need to see him in 4 weeks time. Please make a follow-up appointment to see your PCP [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] @ [Street Address(2) ] in [Hospital1 ], MA within 2 weeks of your discharge. [Telephone/Fax (1) 83241] Please have your blood drawn three times a week Monday, Wednesday and Friday to check your PT and INR so the rehab doctors [Name5 (PTitle) ] adjust your Coumadin dose to get a INR goal of [1-5]. Your heart rate is acceptable up to the low 150's as long as you do not have chest pain, dyspnea, oxygen desaturation to less than 90, ST-elevations on EKG. and are hemodynamically stable. Completed by:[2134-6-19**]	[ "599.0", "434.11", "427.31", "496", "402.90", "784.3", "427.32", "342.90", "303.90" ]	icd9cm	[ [ [] ] ]	[ "38.93", "43.11", "96.6" ]	icd9pcs	[ [ [] ] ]	11504, 11601	5080, 9713	288, 299	11799, 11810	3244, 5057	13007, 14160	1985, 2062		9769, 11481		11622, 11778		9739, 9745			11834, 12984									2077, 2403																								233, 250										327, 1595	2669, 3225										2442, 2653		2427, 2427		1617, 1640	1656, 1969
30,592	152,204	33378	Discharge summary	report	Admission Date: [2157-4-3] Discharge Date: [2157-4-6] Date of Birth: [2091-11-29] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1042] Chief Complaint: GI BLEED Major Surgical or Invasive Procedure: colonoscopy History of Present Illness: This is a 65 year-old female with a history of diverticulitis and IDDM who presented with BRBPR x 1 days. The night PTA she had diarrhea and then later had a BM with BRBPR and noted blood filling the toilet bowel. She denied abdominal pain, N/V, and any other symptoms. She presented to [Hospital1 34] for further evaluation, where her hct was 35. She was hemodynamically stable and was transfused one unit PRBCs. She continued having BRBPR and c/o feeling lightheaded and weak. She was transferred to [Hospital1 18] for possible tagged red cell scan. . In [Hospital1 18] ED: Vitals were stable with BP 130s and HR 70s. 3 PIV's were placed. NGL was negative. She was admitted to ICU for colonoscopy and further management of GIB bleed. Past Medical History: h/o diverticulitis, s/p ruptured diverticulitis 20 yrs ago s/p colostomy and reversal one yr later IDDM CAD s/p stent placement (? 4 yrs ago)-cardiologist is [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 9035] at [Hospital6 10353] HTN hyperlipidemia h/o nephrolithiasis Barrett's Esophagus bipolar d/o Social History: Lives alone. Currently smoking. Family History: No family history of GIB Physical Exam: Vitals: T: 97.3 BP: 144/56 HR: 85 RR: 17 O2Sat: 96% on 2L nc. GEN: Well-appearing, well-nourished, NAD. HEENT: PERRL, sclera anicteric, MMM, OP clear. NECK: Supple, no LAD. COR: RRR, no m/r/g. PULM: Lungs CTAB, no W/R/R. ABD: +BS. Soft, NT, ND. EXT: 2+ b/l pitting edema, with mild erythema and scabbing over the shins c/w chronic venous stasis changes. NEURO: A+Ox3. CN II- XII grossly intact. Strength 5/5. Pertinent Results: [2157-4-3] 07:54PM CK(CPK)-62 [2157-4-3] 07:54PM CK-MB-NotDone cTropnT-0.04* [2157-4-3] 07:54PM HCT-31.7* [2157-4-3] 05:28PM HCT-30.3* [2157-4-3] 12:58PM HCT-34.4* [2157-4-3] 09:58AM GLUCOSE-162* UREA N-39* CREAT-1.7* SODIUM-142 POTASSIUM-4.8 CHLORIDE-110* TOTAL CO2-25 ANION GAP-12 [2157-4-3] 09:58AM estGFR-Using this [2157-4-3] 09:58AM CK(CPK)-83 [2157-4-3] 09:58AM CK-MB-4 cTropnT-0.03* [2157-4-3] 09:58AM WBC-10.9 RBC-3.76* HGB-10.8* HCT-32.3* MCV-86 MCH-28.6 MCHC-33.3 RDW-15.5 [2157-4-3] 09:58AM NEUTS-73.7* LYMPHS-19.8 MONOS-3.9 EOS-2.3 BASOS-0.3 [2157-4-3] 09:58AM PLT COUNT-251 [2157-4-3] 09:58AM PT-12.4 PTT-18.0* INR(PT)-1.0 [2157-4-3] 09:14AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.017 [2157-4-3] 09:14AM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2157-4-3] 09:14AM URINE RBC-0-2+ WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 [2157-4-3] 09:14AM URINE AMORPH-MANY . [2157-4-3] CXR: NG tube tip over gastric fundus. . [2157-4-5] Colonoscopy: Diverticulosis of the sigmoid colon Polyp in the proximal ascending colon Polyp in the sigmoid colon (15cm) Otherwise normal colonoscopy to cecum Brief Hospital Course: This is a 65 year-old female with a history of diverticulitis who presents with lower GI bleed. . #GI Bleed, lower, with acute anemia from blood loss: History notable BRBPR, no abdominal pain, and negative NGL. Given the presence of diverticulosis on colonoscopy, although without active bleeding visualized, this was most likely a diverticular lower GI bleed. The patient was initially admitted to the ICU, but she remained hemodynamically stable and no further bleeding was noted, and so she was transferred to the floor where she remained stable. She received 1 unit of PRBC, after which her hematocrit remained stable on serial checks. She was initially kept on an IV PPI, but following her colonoscopy this was changed to an oral PPI. Anti-hypertensive medications and plavix were initially held, but were restarted prior to discharge. In addition to diverticulosis, the colonoscopy revealed 2 polyps, which were not removed due to her being off plavix for only 3 days. The patient will need a repeat colonoscopy for bx/polypectomy while off plavix. This was discussed with the patient and with her PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 4887]. . # Acute on chronic renal failure: Cr 1.7 on admission, improved to 1.2 with hydration. The patient had pre-renal acute renal failure due to dehydration and hypovolemia in the setting of GI bleeding. She also has chronic kidney disease due to DM and HTN, with baseline [Last Name (STitle) ] 1.2-1.6 according to her PCP. [Name10 (NameIs) ] remained stable at her baseline until the time of discharge. . #Diabetes: Half of her home dose of insulin was given while she was NPO, after which her usual home regimen was resumed with good glucose control. . # H/o coronary artery disease: Patient with history of CAD s/p 3 stents placed ~4 yrs ago. 3 sets of cardiac markers were negative in the setting of nonspecific TWIs on EKG. Plavix was held initially given her GI bleeding. This was restarted prior to discharge, but the patient will need to have a repeat colonoscopy off plavix as an outpatient. Antihypertensives were also initially held, but prior to discharge she wwas restarted on her aspirin, plavix, vytorin, and antihypertensives. . # Bipolar d/o: Continued outpatient wellbutrin and lamictal. . # HTN: Norvasc and lisinoril were held initially in the setting of GI bleed. The patient remained hemodynamically stable and these were restarted prior to discharge. Medications on Admission: aspirin 81 (pt reports not taking) KCl 20 mEq qod (pt does not take) lamictal 50mg daily lasix 80mg alternating with 40mg every other day (pt does not take) lisinopril 20mg daily methylphenidate 20mg daily (pt does not take) norvasc 5mg daily Novolog 70/30 35 units in AM and 50 units at night Plavix 75 mg daily prilosec 20mg [Hospital1 ] vytorin [9-/2129] daily wellbutrin XL 450mg daily Discharge Medications: 1. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO every other day. 5. Lamotrigine 200 mg Tablet Sig: One (1) Tablet PO once a day. 6. Lasix 40 mg Tablet Sig: as directed Tablet PO once a day: 2 tablets alternating with 1 tablet every other day (your usual regimen). 7. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge Sig: as directed Subcutaneous twice a day: 35 units in the morning 50 units at night. 8. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 9. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 10. Vytorin [9-/2129] 10-80 mg Tablet Sig: One (1) Tablet PO once a day. 11. Wellbutrin XL 150 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: gastrointestinal bleeding, diverticulosis Secondary Diagnosis: diabetes type 2, hypertension, coronary artery disease Discharge Condition: good Discharge Instructions: You were hospitalized with a GI bleed. You likely had bleeding from diverticulosis, but this resolved on its own. You also were found to have polyps, which were not removed because you were recently on plavix. You will need a repeat colonoscopy as an outpatient, off plavix, to address this. You should eat a high-fiber diet. You should resume taking all of your usual home medications. We have not made any changes. If you have recurrent rectal bleeding, fever, chills, chest pain, shortness of breath, abdominal pain, or any other concerning symptoms, please call your doctor or return to the emergency room. Followup Instructions: Please make an appointment to followup with your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 4887], within a week. Please discuss the need for a repeat colonoscopy with him.	[ "403.90", "585.9", "250.40", "584.9", "285.1", "414.01", "V45.82", "211.3", "272.4", "296.80", "276.52", "562.12", "530.85" ]	icd9cm	[ [ [] ] ]	[ "45.23", "99.04" ]	icd9pcs	[ [ [] ] ]	7278, 7284	3312, 5780	323, 337	7465, 7472	2001, 3289	8138, 8352	1530, 1556		6229, 7255		7305, 7305		5806, 6206			7496, 8115									1571, 1982																								275, 285										365, 1117				7387, 7444				7324, 7366							1139, 1464	1480, 1514
40,253	162,797	54504	Discharge summary	report	Admission Date: [2184-11-17] Discharge Date: [2184-12-3] Date of Birth: [2102-4-20] Sex: F Service: EMERGENCY Allergies: Iodine Attending:[First Name3 (LF) 2565] Chief Complaint: AMS Major Surgical or Invasive Procedure: Intubation [2184-11-17] History of Present Illness: History is limited. Based on collateral information given patient's current mental status. 82 yo F with history of stable suprasellar meningioma, HLD, HTN, h/o CVA, recent left hand cellulitis last week presents today with altered mental status and transferred to the MICU because of tachycardia. . Per report, patient was seen in the ED for left hand cellulitis and was discharged on Keflex on [2184-11-11]. Per the daughter, the patient only took Keflex for 2 days then stopped it because of nausea. The daughter stated that her mother could not recall how she injured her left hand. Unclear if she had bumped into something. . Over the course of last 2 days, the daughter states that her mother seemed a little more confused. Last night, while eating, the patient stated to the daughter that the lady next to her seemed hungry and should be fed. The daughter said that there was no one else with them at that time. Patient stated that she felt tired and decided to go to bed. This morning, upon awakining, patient's daughter found her disrobed, sitting on the floor, with tea on the floor, 1 slipper on, and pills on the floor. Her home meds and her daughter's Topamax were left on the kitchen. The daughter cannot tell if the patient has taken her Topamax. She thinks that the patient might have taken more Fiorecet. She did not recognize the daughter and was not talking. Per ED report, patient also stated having headache last night. The significant other mentioned that patient was babbling and having difficulty walking, as if she lost her motor function. . Triage vitals were 98.7 136 200/99 18 100% Non-Rebreather. Per EMS, FS was around 131. . In the ED, patient was noted to have rectal temp 102.6F, HR up to the 140s on arrival, and triggerred in the ED. Per ED, patient had altered mental status and could not follow commands. It was noted that she had mouth smacking. She mumbled and moved spontaneously. Left wrist was mildly erythematous. ED reported EKG showing sinus tachycardia. CT head was unchanged. CXR was unremarkable. UA was negative. LP was done. Cultures were sent. Initial FS in the ED was in the 30s, and got an amp of dextrose with FS immediately going up to the 200s. It was thought that this is a spurious [Location (un) 1131]. She received vanc, ceftriaxone, zosyn, and 3L NS. Upon transfer, vitals HR 105-140, BP 161/70 (not hypotensive), O2Sat not avaiable, mid-high 90s on RA now. . On the floor, patient was not following commands and does not answer questions. She mumbles at times. States pain, but cannot localize. . Review of systems: Unable to obtain from the patient currently given her mental status (+) Per HPI Past Medical History: per OMR - HTN - HLD - h/o CVA - migraine headaches - psoriasis - suprasellar meningioma with old deficit of bilateral emporal hemianopsia - osteoarthritis - RA - anxiety - cervical spondylosis - osteopenia Social History: per OMR and family - originally from [Country 6607] - retired bank office worker - stable heterosexual partner - lives with daughter ([Name (NI) ]) - son is also closely involved with her care ([Doctor First Name ]), helps with her finance - Tobacco: never smoked - Alcohol: seldom drinks - baseline dependent of some ADLs- walks independently, requires help with getting in/out of shower, feeds herself, dresses herself but requires help with shoe laces, needs help with medication and finance. Family History: - no siblings - son has allergies - daughter has ovarian cyst & TB exposure - mother had MI and emphysema Physical Exam: Physical Exam on Arrival to the MICU Vitals: T:98.7 axillary, BP: 178/76, P: 125, R:21, O2: 96% RA General: alert, awake, not oriented, not in acute distress HEENT: Sclera anicteric, mucous membrane dry, unable to assess OP as patient does not follow command Neck: supple, JVP not elevated, no LAD Lungs: Limited exam. Poor inspiratory effort. Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: tachycardic, normal S1 and S2, no m/r/g appreciated Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: cool, 1+ DP pulses bilaterally, toes slightly mottled, no clubbing or cyanosis, no edema. Left hand was marked either in the ED or last week (unclear per [Name (NI) ] this afternoon) Neuro: alert, awake, unable to tell where she is. Does not talk much but mumbles at times with minimal slurring of the words. Moves all extremities spontaneously. Unable to assess DTR Pertinent Results: [2184-11-17] 09:45AM BLOOD WBC-12.6* RBC-4.06* Hgb-12.2 Hct-36.6 MCV-90 MCH-30.1 MCHC-33.4 RDW-12.4 Plt Ct-378# [2184-11-17] 09:45AM BLOOD Neuts-91.1* Lymphs-4.1* Monos-4.5 Eos-0.1 Baso-0.2 [2184-11-19] 03:33AM BLOOD PT-13.7* PTT-31.1 INR(PT)-1.2* [2184-11-17] 09:45AM BLOOD Glucose-386* UreaN-41* Creat-1.8* Na-128* K-4.3 Cl-88* HCO3-30 AnGap-14 [2184-11-17] 09:45AM BLOOD ALT-26 AST-29 AlkPhos-96 TotBili-0.3 [2184-11-17] 02:43PM BLOOD Albumin-3.6 Calcium-7.8* Phos-2.8 Mg-1.7 [2184-11-18] 02:23AM BLOOD Phenyto-12.2 Phenyfr-2.0 %Phenyf-16 [2184-11-27] 19:13 HERPES SIMPLEX VIRUS PCR Result ------ HERPES SIMPLEX TYPE I DNA DETECTED CRITICAL RESULT Analyte Specific Reagent This test was developed and its performance characteristics determined by Laboratory Medicine and Pathology, [Hospital3 14659]. This test has not been cleared or approved by the U.S. Food and Drug Administration. [2184-11-17] Test Requested -------------- Herpes Simplex Virus PCR Specimen Source: Cerebrospinal Fluid Result ------ Negative Brief Hospital Course: 82 yo F with h/o CVA, suprasellar meningioma, and other medical issues transferred to the ICU for tachycardia and AMS. . Neurology was consulted soon after patient arrived the floor. EEG was set up and found patient to be in status epilepticus. Patient remained seizing despite high doses of sedatives requiring intubation for airway protection. Patient was initially on empiric antiviral therapy for HSV encephalitis however result was negative and acyclovir was subsequently discontinued. Continuous EEG monitoring was continued until no seizure activity was detected and versed was slowly weaned off. After weaning of versed, pt remained persistently obtunded and somnolent. MRI revealed concern for ongoing temporal lobe process as well as embolic phenomenon. TTE with bubble study revealed a PFO. A repeat LP was completed for concern of limpic encephalitis. CSF was sent to [Hospital3 14659] for investigation of antibodies are still pending at this time. Repeat HSV PCR was sent and subsequently turned positive. Acyclovir was started at day of LP and was continued. Pt however continued to remain obtunded despite continued therapy. After waiting over a week since beginning acyclovir for signs of improvement (of which there were none and patient declined in neurological status), the HCP (son) made decision to change goals of care to comfort. Patient was extubated and died with her family at her bedside. Medications on Admission: Per OMR - Fioricet 50-325-40mg, 1 tab, TID PRN - clobetasol 0.05% ointment [Hospital1 ] to areas of psoriasis. 2 weeks on and 2 weeks off. - clobetasol 0.05% foam to the scalp daily 2 weeks on and 2 weeks off. - desonide 0.05% ointment [Hospital1 ] 2 weeks on and 2 weeks off - valium 2.5 mg [Hospital1 ]. ON VALIUM CONTRACT. - compression stockings - HCTZ 12.5 mg daily - hydrocortisone 2.5 % cream [Hospital1 ] - simvastatin 10 mg daily - ASA 325 mg daily Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[2184-12-3]	[ "714.0", "518.84", "721.0", "785.0", "682.4", "584.9", "225.2", "696.1", "438.89", "300.00", "346.90", "692.9", "745.5", "729.89", "427.1", "453.40", "401.9", "E879.8", "E849.7", "345.40", "V49.86", "458.29", "276.52", "780.97", "733.90" ]	icd9cm	[ [ [] ] ]	[ "38.97", "89.19", "03.31", "96.04", "96.72" ]	icd9pcs	[ [ [] ] ]	7990, 7999	6008, 7432	274, 303	8050, 8059	4904, 5985	8115, 8153	3803, 3911		7958, 7967		8020, 8029		7458, 7935			8083, 8092									3926, 4885																			2947, 3029					230, 236										331, 2927															3051, 3259	3275, 3787
41,289	190,843	47107	Discharge summary	report	Admission Date: [2133-8-10] Discharge Date: [2133-8-15] Service: MEDICINE Allergies: Amoxicillin / Dilantin / Adhesive Tape / Atenolol / Zestril / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 20224] Chief Complaint: Bleeding from urethra Major Surgical or Invasive Procedure: Cystoscopy with urethral polypectomy and cauterization of bleeding in urethra [2133-8-12] History of Present Illness: This is a [Age over 90 ] year-old female with a history of HTN, a-fib on plavix, hypothyroidsim (Grave's s/p thyroidectomy), chronic renal disease (baseline 1-1.3), s/p urethral polyp excision 7 days ago who presents with bleeding. She has had an extensive 2 year history of bleeding requirng cautery to the polyp. She underwent removal at [Hospital3 ] 7 days ago and bleeding had stopped post-op for several days. However, the morning of [8-10] she awoke to her linens satuarted with blood and was brought to the ED. She had restarted her plavix 2 days prior to admission after stopping them for the surgery. . In the ED, 97.5 HR> 58, BP 102/48 RR:16, 99% RA. Her initial Hct was 25.9. A Pelvic U/S was performed and showed likely hematoma in the bladder and 3mm endometrial stripe. She was evaluated by both Urogyn and Urology. A speculum exam did not show bleeding from the vagina or a fisulous tract. A foley was placed and gauze was placed in the vaginal vault. Urology irrigated the foley and removed some clots and her urine briefly cleared. However, she again began to bleed and repeat Hct was 20.0. She was hypotensive to the 80/40's and responded to 1L IVF bolus. She was transfused 1U of pRBC and transferred to the [Hospital Unit Name 153] for further management. She was also given cipro and UA was grossly positive, but patient denied dysuria, fevers, chills. Past Medical History: 1. Hypertension 2. Shingles - [2127] 3. Chronic kidney disease (baseline 1.0-1.3) 4. Pancytopenia - Negative SPEP and UPEP in the past. Felt to be most likely due to myelodysplastic syndrome. 5. TIA - [2122] 6. Atrial fibrillation - The patient is not anticoagulated due to a past subdural hematoma. 7. Subdural hematoma 8. Sinus arrest with junctional tachycardia in the mid [2114] requiring pacemaker placement 9. Graves' disease status post thyroidectomy and radiation 10. Hypothyroidism 11. Osteoarthritis 12. Falls 13. Thoracic aortic aneurysm at the level of the diaphragm - A CT was obtain for comparison on [2132-11-13] and aneurysm was unchanged. It measured 4 cm. 14. Colon polyps status post removal - [2130] 15. Anemia 16. Hemorrhoids 17. Urethral polyps 18. History of laryngeal spasm 19. Frontal gait syndrome - Diagnosed by Dr. [Last Name (STitle) ] in [2128]. 20. Urethral polyp s/p cautery ed Social History: The patient is widowed and lives with her daughter [Name (NI) ] in [Name (NI) 745]. She is retired from working as a bookkeeper. There are no stairs within the home but there are 14 stairs to leave the house. No alcohol or tobacco. The patient utilizes a walker. Family History: Her mother had breast cancer, and died of heart disease at age 84. Her father died of CAD at age 78. Her brother died of appendiceal cancer at age 72. Physical Exam: Vitals: T:95.5 BP:120/43 HR:60 RR:13 O2Sat:100% GEN: elderly female, frail appearing, but NAD HEENT: EOMI, PERRL, sclera anicteric, MMM, OP Clear NECK: No JVD, no cervical lymphadenopathy, trachea midline COR: RRR, II/VI SEM, normal S1 S2 PULM: bibasilar crackles, otherwise CTAB, no W/R ABD: Soft, NT, ND, +BS EXT: No C/C/E NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [2133-8-13] 06:15AM BLOOD WBC-5.9 RBC-3.78* Hgb-10.7* Hct-31.4* MCV-83 MCH-28.4 MCHC-34.2 RDW-16.4* Plt Ct-96* [2133-8-13] 01:11AM BLOOD Hct-32.7* [2133-8-12] 08:30PM BLOOD WBC-5.5 RBC-3.26* Hgb-9.2* Hct-27.7* MCV-85 MCH-28.3 MCHC-33.3 RDW-16.0* Plt Ct-94* [2133-8-12] 02:40PM BLOOD WBC-4.9 RBC-3.95* Hgb-11.2* Hct-33.5* MCV-85 MCH-28.5 MCHC-33.5 RDW-16.4* Plt Ct-114* [2133-8-12] 08:28AM BLOOD WBC-4.9 RBC-4.01* Hgb-11.5* Hct-33.6* MCV-84 MCH-28.6 MCHC-34.2 RDW-16.4* Plt Ct-107* [2133-8-12] 03:38AM BLOOD WBC-5.3 RBC-3.74* Hgb-10.7* Hct-31.9* MCV-85 MCH-28.5 MCHC-33.5 RDW-16.0* Plt Ct-94* [2133-8-11] 11:08PM BLOOD WBC-6.2 RBC-3.89* Hgb-11.0* Hct-33.0* MCV-85 MCH-28.2 MCHC-33.3 RDW-15.8* Plt Ct-87* [2133-8-11] 08:04PM BLOOD WBC-4.6 RBC-3.87* Hgb-11.2* Hct-33.1# MCV-86 MCH-28.9 MCHC-33.8 RDW-15.4 Plt Ct-87 [2133-8-11] 11:25AM BLOOD Hct-20.0# [2133-8-11] 03:20AM BLOOD WBC-3.6 RBC-3.23# Hgb-9.6# Hct-28.5* MCV-88 MCH-29.6 MCHC-33.7 RDW-14.7 Plt Ct-98* [2133-8-11] 12:40AM BLOOD Hct-23.9* [2133-8-10] 08:40PM BLOOD WBC-3.8* RBC-2.31* Hgb-6.6* Hct-20.0* MCV-86 MCH-28.5 MCHC-33.0 RDW-15.2 Plt Ct-130* [2133-8-10] 01:50PM BLOOD WBC-4.3 RBC-2.93* Hgb-8.2* Hct-25.9* MCV-88 MCH-28.2 MCHC-31.9 RDW-14.6 Plt Ct-155 [2133-8-10] 08:40PM BLOOD Neuts-76.2* Lymphs-18.0 Monos-3.7 Eos-1.4 Baso-0.7 [2133-8-10] 01:50PM BLOOD Neuts-71.4* Lymphs-19.9 Monos-4.2 Eos-3.5 Baso-0.9 [2133-8-12] 03:38AM BLOOD PT-12.7 PTT-28.8 INR(PT)-1.1 [2133-8-11] 11:08PM BLOOD PT-12.5 PTT-28.2 INR(PT)-1.0 [2133-8-11] 12:04AM BLOOD PT-13.2 PTT-26.9 INR(PT)-1.1 [2133-8-11] 08:10PM BLOOD FDP-40-80* [2133-8-11] 08:04PM BLOOD Fibrino-178 [2133-8-13] 06:15AM BLOOD Glucose-68* UreaN-21* Creat-1.0 Na-139 K-4.1 Cl-111* HCO3-13* AnGap-19 [2133-8-12] 10:22PM BLOOD Glucose-72 UreaN-23* Creat-0.8 Na-137 K-4.0 Cl-110* HCO3-14* AnGap-17 [2133-8-12] 05:20AM BLOOD Glucose-73 UreaN-21* Creat-0.7 Na-140 K-3.8 Cl-114* HCO3-17* AnGap-13 [2133-8-12] 03:38AM BLOOD Glucose-76 UreaN-21* Creat-0.9 Na-136 K-6.3* Cl-111* HCO3-18* AnGap-13 [2133-8-11] 11:08PM BLOOD Glucose-92 UreaN-21* Creat-0.8 Na-138 K-3.7 Cl-111* HCO3-18* AnGap-13 [2133-8-11] 03:20AM BLOOD Glucose-90 UreaN-23* Creat-1.1 Na-139 K-5.3* Cl-110* HCO3-20* AnGap-14 [2133-8-10] 08:40PM BLOOD Glucose-122* UreaN-28* Creat-1.3* Na-139 K-4.3 Cl-107 HCO3-24 AnGap-12 [2133-8-10] 01:50PM BLOOD Glucose-113* UreaN-29* Creat-1.5* Na-138 K-4.1 Cl-104 HCO3-23 AnGap-15 [2133-8-11] 03:20AM BLOOD ALT-10 AST-38 AlkPhos-36* TotBili-0.6 [2133-8-13] 06:15AM BLOOD Calcium-7.4* Phos-3.6 Mg-1.5* [2133-8-12] 10:22PM BLOOD Calcium-7.4* Phos-3.6 Mg-1.6 [2133-8-12] 05:20AM BLOOD Calcium-6.9* Phos-3.0 Mg-1.8 [2133-8-11] 03:20AM BLOOD Albumin-2.9* Calcium-7.4* Phos-4.2 Mg-2.1 [2133-8-11] 08:10PM BLOOD D-Dimer-[Numeric Identifier ]* [2133-8-13] 12:21AM BLOOD Type-ART Temp-35.0 pO2-78* pCO2-25* pH-7.39 calTCO2-16* Base XS--7 [2133-8-13] 12:21AM BLOOD Lactate-1.4 [2133-8-12] 10:34PM BLOOD Lactate-1.3 [2133-8-11] 03:47AM URINE Color-Red Appear-Cloudy Sp [Last Name (un) ]-<1.005 [2133-8-11] 03:47AM URINE Blood-LG Nitrite-NEG Protein->300 Glucose-100 Ketone-40 Bilirub-LG Urobiln->8 pH-8.5* Leuks-LG [2133-8-11] 03:47AM URINE RBC->50 WBC-[12-11]* Bacteri-FEW Yeast-NONE Epi-0 [2133-8-10] 08:40PM URINE Color-Red Appear-Cloudy Sp [Last Name (un) ]-1.010 [2133-8-10] 08:40PM URINE Blood-LG Nitrite-POS Protein-300 Glucose-250 Ketone- Bilirub-LG Urobiln-8* pH-9.0* Leuks-LG [2133-8-10] 08:40PM URINE RBC->50 WBC-21-50* Bacteri-MOD Yeast-NONE Epi-0 Pelvic US [8-10]: 1. Normal 3-mm endometrium. 2. Large heterogeneous mainly echogenic mass within the bladder is consistent with a hematoma/clot, although other etiologies are possible. Correlate clinically. 3. No adnexal mass. 4. Given the history of ureteral polyps, note that this study is not sensitive in assessing this. CXR [2133-8-11]: IMPRESSION: No acute findings with no change since the previous study. Path [2133-8-12]: 1. Polypoid fragments of markedly cauterized fibroconnective tissue with acute and chronic inflammation and thrombus. 2. No definitive urothelium or squamous epithelium identified; see note. ECG [2133-8-12]: A-V sequentially paced rhythm. Compared to the previous tracing of [2133-6-17] no significant change. CXR [2133-8-13]: Bilateral pleural effusions with adjacent atelectasis are new. Mild to moderate cardiomegaly is stable. Aorta is tortuous. There is no pneumothorax. Right transvenous pacemaker leads terminate in the standard position in the right atrium and right ventricle. No evidence of CHF. Urine culture: No growth [8-10], [8-11] Blood cultures 7/21 no growth to date at time of discharge. Brief Hospital Course: This is a [Age over 90 ] year-old woman with a hypertension and atrial fibrilation on plavix who presented with hematuria. She was found to have hemodynamically significant bleeding with SBP to 80, hct to 20. She also had a significant clot in her bladder. She had a 3 way irrigating catheter placed and was transfused total of 5 units of packed red cells. Her bleeding persisted, though her vital signs and hct stabilized. She was taken to the OR with urogyn [8-12] and had cystoscopy with polypectomy and cautery. Her bleeding improved. She had additional small bleeding requiring replacement of 3 way irrigating catheter but this stopped [8-14] and her hct was stable so she was discharged with the catheter on [8-15] to follow up in short interval with Dr. [Last Name (STitle) ]. During this time her plavix was held, which was given for a.fib. This was discussed with Dr. [Last Name (STitle) ], her cardiologist, who agreed to stopping this in the short term, with discussion of restarting it on follow up. Also during this time her amlodipine was held, but her blood pressure improved to 140/60 so this was restarted. She developed an anion gap and non-gap acidosis thought due to ketones from being npo and hyperchloremia for ivf. This improved by discharge. She was noted to have bacteriuria so was treated with ciprofloxacin empirically for 7 day course but her urine cultures were no growth. She was continued on levothyroxine for hypothyroidism. Medications on Admission: colace miralax estrace cream plavix 75mg daily amlodipine 2.5mg daily levothyroxine 50mcg daily with extra [1-23] tab on sunday calcium and vitamin D iron 325 daily Discharge Medications: 1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): plus additional [1-23] tab on sunday. 2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. Disp:1 Tablet(s) Refills:0 4. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 5. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) packet PO once a day as needed for constipation. 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 8. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1) Tablet PO three times a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Hemturia secondary to urethral polyp Atrial fibrilation, s/p pacemaker Hypertension Acute blood loss anemia Thrombocytopenia Urinary tract infection Discharge Condition: Stable vital signs with BP 140/64, HR 60, comfortable, with foley in place draining clear urine. Discharge Instructions: You were admitted to the hospital with bleeding from your urethra. You required blood transfusions. You went to the OR to stabilize the bleeding. Your blood count stabilized and your bleeding stopped. You are being discharged to follow up with Dr. [Last Name (STitle) ] next week. Due to bleeding your plavix was stopped. You are being treated for a urinary tract infection, for which you need one additional day of ciprofloxacin. If you develop additional bleeding, dizziness or lightheadedness, fevers or chills, pain at the catheter, please call Dr. [Last Name (STitle) ] or return to the ER at [Hospital3 ] for evaluation. Followup Instructions: Please follow up with Dr. [First Name (STitle) ] [Name (STitle) ] next Wednesday, [2133-8-19]. Please call for this appointment. Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 62] Date/Time:[2133-10-8] 10:00 Provider: [Last Name (NamePattern4) ]. [First Name11 (Name Pattern1) 275] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Phone:[Telephone/Fax (1) 62] Date/Time:[2133-10-8] 10:40 Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 719] Date/Time:[2133-10-19] 10:00	[ "V12.54", "599.0", "E879.8", "E934.8", "998.11", "284.1", "285.1", "V45.01", "427.31", "276.2", "244.0", "403.90", "238.75", "293.0", "441.2", "585.3" ]	icd9cm	[ [ [] ] ]	[ "58.31" ]	icd9pcs	[ [ [] ] ]	11171, 11229	8719, 10201	313, 409	11422, 11521	3874, 8696	12209, 12794	3096, 3250		10421, 11148		11250, 11401		10227, 10398			11545, 12186									3265, 3855																								252, 275										437, 1829															1851, 2791	2807, 3080
5,727	125,861	51923	Discharge summary	report	Admission Date: [2155-3-5] Discharge Date: [2155-3-10] Date of Birth: [2096-11-3] Sex: M Service: MEDICINE Allergies: Morphine Attending:[First Name3 (LF) 678] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: hemodialysis History of Present Illness: HPI: Mr. [Known lastname 107485] is a 58 year old man with history of diabetes, ESRD on HD (anuric), CAD s/p MI, CHF (EF 30%), a-fib/flutter and substance abuse(tobacco, EtOH, and crack cocaine) who presents with p/w melena x2 days, and weakness as well as increased dyspnea on exertion. He also states that he has "throbbing" left sided chest pain that has been ongoing for days-episodes come on all of a suddent and can last for hours, usually. He missed his HD appointment for dialysis yesterday [2-15] fatigue. He also complains of a productive cough with white sputum for several days. He denies N/V/D and did not take any of his medications on the day of presentation. He states he was on antibiotics for the flu last week. He reports that his back is pruritic. He notes recent cocaine use in the past two days. . In the ED his vitals were; T97.6, HR 106, BP 135/81, RR18, O2 96% His labs were significant for Hct 22 (down from his baseline of 26)and he was guaiac positive on physical exam. He received 2U of PRBCs. While in the ED his HR increased to the 140s intermittently, he denied cp at that time, he received metoprolol 25mg po times one as well as a 5mg IV dose. He was given IV dilaudid for lower abdominal pain with good effect and admitted to the MICU for lower GI bleed. He was seen by nephrology in the ED . He has had an extensive workup in the past including (at least) eight endoscopies-most recently in [2154-8-14], three colonoscopies-last one in [2153], one enteroscopy, and a capsule camera study-in [2153]; all studies have been negative with the exception of small AVM's in the duodenum seen and cauterized on one study, as well as minor jejunal erosions noted on the capsule camera study. During his last admission (end of [Month (only) 359]), he required 7 units of pRBC's. Past Medical History: #) ESRD on hemodialysis #) Type II diabetes mellitus #) CAD s/p MI, MIBI in [11-19] showed reversible defects inferior/ latateral #) CHF with EF 30% and severe global hypokinesis #) Hypertension #) Dyslipidemia #) Atrial fibrillation #) History of gastrointestinal bleed: Duodenal, jejunal, and gastric AVMs, s/p thermal therapy; sigmoid diverticuli #) Chronic pancreatitis #) Hepatitis C #) GERD #) Gout, s/p arthroscopy with medial meniscectomy [5-/2149] #) Depression, s/p multiple hospitalizations due to SI #) Polysubstance abuse: crack cocaine, EtOH, tobacco #) Erectile dysfunction, s/p inflatable penile prosthesis [5-/2148] Social History: Smokes 3 cigs/day. Hx of alcohol abuse, with DTs and detoxification. Active crack cocaine use. Married, though distant from wife. [Name (NI) ] girlfriend who also uses cocaine. Family History: Father with alcoholism, cousin with [Name2 (NI) 14165] cell. Mother with renal failure, d. 58. Twin brother and son with kidney disease. Pertinent Results: [2155-3-5] 09:55PM POTASSIUM-6.1* [2155-3-5] 09:55PM CK(CPK)-122 [2155-3-5] 09:55PM CK-MB-11* MB INDX-9.0* cTropnT-0.39* [2155-3-5] 09:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2155-3-5] 06:34PM K+-5.8* [2155-3-5] 12:15PM GLUCOSE-292* UREA N-56* CREAT-5.7* SODIUM-135 POTASSIUM-5.4* CHLORIDE-98 TOTAL CO2-24 ANION GAP-18 [2155-3-5] 12:15PM estGFR-Using this [2155-3-5] 12:15PM ALT(SGPT)-19 AST(SGOT)-18 LD(LDH)-207 CK(CPK)-92 ALK PHOS-155* TOT BILI-0.5 [2155-3-5] 12:15PM CK-MB-NotDone cTropnT-0.34* [2155-3-5] 12:15PM ALBUMIN-3.7 [2155-3-5] 12:15PM WBC-4.6 RBC-2.65* HGB-7.0* HCT-22.3* MCV-84 MCH-26.4* MCHC-31.3 RDW-19.4* [2155-3-5] 12:15PM NEUTS-74.6* LYMPHS-16.4* MONOS-6.2 EOS-2.2 BASOS-0.5 [2155-3-5] 12:15PM PLT COUNT-278 Brief Hospital Course: #) DOE-Symptoms started several days prior to admission and differential included volume overload from CHF or renal failure, PNA as seen on CXR, ischemia or most likely anemia. Pt was given 2 units of prbcs with improvement in his symptoms. There was an intial concern for pneumonia but pt was afebrile, no elevation in his WBC but did have a cough. He was not given any antibiotics for this. Pt ruled out for MI and was monitored on telemetry with no events. He did not require any additional transfusions. . #) Melena-Pt states he has had black stools for 4 days, Hct is not far below baseline, rectal exam in ED was guaiac positive. He has had an EGD as recently as [8-21] that showed small AVMs, had two bm's that were guaiac negative this am, hct has been stable-not much of a decrease from baseline. He was given 2 U prbcs with improvement in his Hct; and he subsequently remained near his baseline of 29-30. Pt was given Protonix daily and no other further intervention felt necessary per GI as he has had numerous colonscopies and EGDs in the past. . #) Anemia. Most likely acute blood-loss anemia from a GI source, as well as chronic anemia from CRI. He recieved 2 Units while in the hospital with stabilization of his anemia to baseline. Per GI there were no further interventions done. . #) ESRD on HD-Pt was seen during his hospitalization by renal. He received HD while in house. He also had an AV Fistulogram on [3-10] with successful balloon angioplasty of the mid cephalic vein and the more central cephalic stenosis using the 6 mm cutting balloon and a 4 mm regular balloon. Renal followed pt during his stay and felt he could go home with his regular HD schedule. He was [Month/Year (2) 1988] for dialysis the day after admission (Tues) at [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 9449] Dialysis Center [Last Name (NamePattern1) 84701]. [Location (un) 669], [Numeric Identifier 18406]. . #) Hyperkalemia-Likely secondary to renal failure and he received kayexalate in the ED with improvement in his K. No further treatment needed beyond his routine HD. . #) CAD: Pt had CE drawn which showed Troponin of 0.34, 0.39 on this admission, no EKG changes concerning for ischemia felt to be likely [2-15] demand in the setting of renal failure. No further enzymes done; his aspirin was intially held in the setting of a bleed but restarted once stable. He was continued on his home labetolol, lisinopril and atorvastatin. . #) Rhythm-h/o a-fib a-flutter not anticoagulated [2-15] GIB, in ED was in rapid a-fib/a-flutter, on labetalol 200mg po bid at home, has been well rate controlled while here. He was continued and discharged on his regular home medications. . #) Substance abuse-Pt was put in a CIWA scale while in house but it was not felt he was in withdrawal during this hospitalization. . #) Diabetes. Pt was continued on home insulin regimen. Medications on Admission: Iron sulfate Atorvastatin 20mg daily Insulin NPH 30 units qAM, 20 units qPM Labetalol 200mg [Hospital1 ] Pantoprazole 40mg daily Aspirin 325mg daily Lisinopril 40mg daily Discharge Medications: 1. Labetalol 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Insulin Glargine 100 unit/mL Cartridge Sig: As directed units Subcutaneous once a day: 30 units in AM, 20 units at bedtime. 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: End Stage Renal Disease CHF exacerbation GI Bleeding requiring transfusions Demand Ischemia Delerium Discharge Condition: stable Stable, Discharge Instructions: You were admitted to the hospital for evaluation of bleeding in your stools and shortness of breath. You received 2 units of blood and were given hemodialysis. You were then monitored for improvement. . Please call your doctor or return to the ED if you develop any symptoms of chest pain, shortness of breath, bleeding, Temperature > 101, or any other symptoms concerning to you. . There were no changes to your home medications PLEASE make sure you go to dialysis TOMORROW (tues) to resume your regular dialysis schedule. Followup Instructions: Please continue to follow your regular dialysis schedule Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2155-4-9] 8:30 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(1) 684]	[ "276.7", "577.1", "311", "305.00", "305.90", "428.0", "585.6", "427.32", "285.21", "414.01", "996.73", "305.1", "285.1", "V58.67", "537.83", "274.9", "070.70", "V45.1", "250.00", "427.31", "E937.9", "403.91", "698.8" ]	icd9cm	[ [ [] ] ]	[ "39.50", "00.40", "99.04", "39.95" ]	icd9pcs	[ [ [] ] ]	7802, 7808	4065, 7039	276, 290	7953, 7970	3196, 4042	8547, 8817	3034, 3177		7265, 7779		7829, 7932		7065, 7242			7994, 8522																																	228, 238										318, 2149															2171, 2819	2835, 3018
6,418	150,203	26124	Discharge summary	report	Admission Date: [2175-2-10] Discharge Date: [2175-2-22] Date of Birth: [2104-3-3] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Progressive dyspnea Major Surgical or Invasive Procedure: [2175-2-15] - Minimally Invasive Mitral Valve Replacement (25mm [Last Name (un) 3843] [Doctor Last Name ] Pericardial Tissue Valve) History of Present Illness: 70 year old female transferred from outside hospital for mitral valve surgery. She has had progressive shortness of breath over the past 10 days. An echo on [2175-2-9] revealed worsening MR with a ruptured chordea. She is being evaluated for surgery. Past Medical History: MVP Asthma Osteopenia Arthritis Vein Stripping Social History: Lives with husband. [Name (NI) 1403] as artist. Drinks wine with dinner. Quit smoking in [2139] after [1-16] ppd for 14 years.. Family History: None Physical Exam: Vitals: BP 116/57, HR 65 General: well developed female in no acute distress lying flat after cath HEENT: oropharynx benig Neck: supple, no JVD Heart: regular rate, normal s1s2, [3-20] late systolic murmur Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema Pulses: 2+ distally Neuro: nonfocal Pertinent Results: [2175-2-10] 04:00PM PT-12.0 PTT-26.9 INR(PT)-1.0 [2175-2-10] 04:00PM PLT COUNT-287 [2175-2-10] 04:00PM WBC-5.7 RBC-3.98* HGB-12.3 HCT-34.7* MCV-87 MCH-31.0 MCHC-35.5* RDW-12.9 [2175-2-10] 04:00PM ALT(SGPT)-13 AST(SGOT)-20 ALK PHOS-50 AMYLASE-99 TOT BILI-0.5 [2175-2-10] 04:00PM GLUCOSE-114* UREA N-22* CREAT-0.7 SODIUM-141 POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-27 ANION GAP-9 [2175-2-20] 10:10AM BLOOD WBC-8.2 RBC-4.35 Hgb-13.6 Hct-38.9 MCV-89 MCH-31.2 MCHC-34.9 RDW-14.4 Plt Ct-263 [2175-2-20] 10:10AM BLOOD Plt Ct-263 [2175-2-20] 10:10AM BLOOD Glucose-171* UreaN-19 Creat-0.8 Na-139 K-4.3 Cl-105 HCO3-26 AnGap-12 [2175-2-13] ECHO 1. The left atrium is mildly dilated. The left atrium is elongated. 2.Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). 3.Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic arch is mildly dilated. 5.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. 6. The mitral valve leaflets are thickened.There is moderate/severe mitral valve prolapse of the posterior mitral valve leaflet with at least moderate (2+) mitral regurgitation is seen. 7.There is no pericardial effusion. [2175-2-22] CXR 1) Improvement of the small right apical pneumothorax. 2) Stable small bilateral pleural effusions. 3) Mild pulmonary congestion remains unchanged in comparison to the previous film. [Last Name (NamePattern4) 4125]ospital Course: Mrs. [Known lastname ] was admitted to the [Hospital1 18] via transfer from an outside hospital for further management of her mitral valve disease. She was evaluated by the cardiac surgery service and worked-up in the usual preoperative manner. An echocardiogram was performed which revealed moderate to severe mitral regurgitation with severe prolapse and a normal ejection fraction. A dental consult was obtained and after obtaining Panorex films, Mrs. [Known lastname ] was cleared orally for surgery. On [2175-2-15], Mrs. [Known lastname ] was taken to the operating room where she underwent a minimally invasive mitral valve replacement with a 25mm [Last Name (un) 3843] [Doctor First Name 7624] pericardial tissue valve. Postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Mrs. [Known lastname ] awoke neurologically intact and was extubated. Aspirin and an ace inhibitor were started. She was then transferred to the cardiac surgical step down unit for further recovery. She was gently diuresed towards her preoperative weight. The physical therapy service was consulted for assistance with her strength and mobility. She developed atrial fibrillation which converted to normal sinus rhythm with beta blockade. A chest x-ray revealed a pneumothorax without the presence of an air leak. As she had a persistent pneumothorax with her chest tube on water seal, the thoracic surgery service was consulted. Her pneumothorax slowly became smaller and her chest tube was removed on [2175-2-22]. A follow-up chest x-ray showed improvement in her small right pneumothorax. levofloxacin was started for a urinary tract infection. Mrs. [Known lastname ] continued to make steady progress and was discharged home on postoperative day seven. She will follow-up with Dr. [Last Name (Prefixes) ], her cardiologist and her primary care physician as an outpatient. Medications on Admission: Flovent Atrovent Fosamax Vitamins Oscal Tums Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:90 Tablet, Delayed Release (E.C.)(s) Refills:4 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:1 1 Refills:2 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:10 Tablet(s) Refills:0 5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO every twelve (12) hours for 5 days: Take with lasix and stop when lasix stopped. . Disp:10 Tab Sust.Rel. Particle/Crystal(s) Refills:0 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:1 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:1 1 Refills:0 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Take while taking pain medicine. You [Doctor First Name ] stop when no longer taking narcotics. . Disp:60 Capsule(s) Refills:0 11. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:30 Tablet Sustained Release 24HR(s) Refills:1 12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:5 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Last Name (un) 2646] Discharge Diagnosis: Mitral valve prolapse Asthma Osteopenia Pneumothorax Arthritis Urinary Tract Infection Vein Stripping Cholecystectomy Atrial Fibrillation Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These included redness, drainage or increased pain. 2) Report any fever greater then 100.5 3) Report any weight gain of greater then 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lifting greater then 10 pounds for 10 weeks 5) No driving for 1 month. 6) Lasix and potassium to be taken twice daily for 5 days. 7) Take levofloxacin for five days and then stop for urinary tract infection. 8) Call with any questions or concerns. [Last Name (NamePattern4) 2138]p Instructions: Dr. [Last Name (Prefixes) ] [Telephone/Fax (1) 170] Follow-up appointment should be in 1 month. Follow-up with Cardiologist Dr. [Last Name (STitle) 3659] in [1-16] weeks. Follow-up with Primary Care Physician [Last Name (NamePattern4) ]. [First Name (STitle) 4640] in 2 weeks. Please call all providers to schedule appointments. Completed by:[2175-2-22]	[ "212.7", "511.9", "424.0", "274.9", "E849.8", "512.1", "427.31", "733.90", "493.90", "E879.8", "429.0" ]	icd9cm	[ [ [] ] ]	[ "99.04", "35.23" ]	icd9pcs	[ [ [] ] ]	6838, 6894		340, 486	7076, 7083	1398, 2978		1014, 1020		5088, 6815		6915, 7055		5019, 5065			7107, 7582			7633, 8018						1035, 1379														3029, 4993										281, 302										514, 770															792, 841	857, 998
67,481	186,264	24461	Discharge summary	report	Admission Date: [2114-3-7] Discharge Date: [2114-3-9] Date of Birth: [2038-3-26] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern4) 290] Chief Complaint: respiratory failure/pulmonary embolus Major Surgical or Invasive Procedure: intubation History of Present Illness: Mr. [Known lastname 61867] is a 75 yo male with a history of TBI, GI bleed in [2111], CKI, prostate cancer, and recent discharge from [Hospital1 18] on [2114-2-14] for aspiration pneumonia, who was noted at his rehab on the morning of [2114-3-6] to be SOB with an oxygen sat of 94% on RA. Per OSH records, the patient stated that he had felt SOB for two days, but denied cough, CP, N/V/D/C, leg pain or LE swelling. A CXR at the rehab on [2114-3-6] was normal however the patient developed an oxygen requirement, satting 93-95% on 2L NC. Despite treatment with q4H duonebs, he continued to experience SOB, difficulty breathing, and agitation. He was brought by EMS to NWH on [2114-3-7] where he was found to be A=Ox3,with vitals: T: 98, BP: 139/60, P: 75, RR: 32, and POx of 88% on RA. EKG showed no change from previous. Labs were notable for a elevated d-dimer of 3.4 and Cr 1.3. A CTA chest at the OSH showed multiple PEs. Although he remained HD stable, he began to have increasing work of breathing and was subsequently intubated. He was given 70 mg of Lovenox,500cc bolus of NS, and duonebs at OSH. At the time of transfer to [Hospital1 18] vitals were: BP 159/85 RR 17 100% AC 550x16 Fi02 100. . In the ED, initial vs were: afebrile, P: 82, BP: 139/48, RR: 17, O2 sat 99% vented. The patient was transferred to the [Hospital Unit Name 153] for further management. EKG showed LBBB but NSR. . On the floor, the patient was sedated and intubated. Vitals were: T: 101F, P: 69, RR: 18, BP: 122/52, with oxygen sat of 99% on FiO2 100, VT 550, f 16, PEEP 5. . Review of sytems: unable to obtain. Past Medical History: - Complex regional pain syndrome - Traumatic brain injury s/p remote MVC in [2054], slurred speech and R hemiplegia at [Year (4 digits) 5348] - Prostate ca ([9-/2109]--operated by Dr. [Last Name (STitle) 770] - CRI - h/o GI bleed admitted [4-/2113] --EGD with esophageal ulcers and antral gastritis. - h/o Barrett's esophagus - Iron deficiency anemia - Thrombocytopenia - HTN - Incontinence - h/o LBBB Social History: Lives at [Hospital 8218] Rehab. Tob x 15 yrs (stopped 40 yrs ago), no ETOH recently (though may have had Etoh hx), no IVDU. Sister is [Name (NI) ], guardian: [Name (NI) 16883] [Telephone/Fax (1) 61863] (home: [Telephone/Fax (1) 61868]). Fully dependent for ADLs. Family History: n/c Physical Exam: General: sedated and intubated HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP 8cm, no LAD Lungs: diffuse rhonchi, no wheezes/rales 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 in place draining clear yellow urine. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, edema. Pertinent Results: [2114-3-7] CXR: IMPRESSION: 1. ET tube approximately 2.4 cm above the carina. 2. Mild fluid overload. 3. Basilar atelectasis. However, developing infection cannot be excluded. [2114-3-7] CXR: FINDINGS: In comparison with study of [2-9], there is now an endotracheal tube in place with its tip approximately 2.8 cm above the carina. Nasogastric tube extends into the distal stomach. There is enlargement of the cardiac silhouette with bilateral pleural effusions and extension of fluid into the minor fissure on the right. Retrocardiac opacification is consistent with volume loss or, in the appropriate setting, consolidation in the left lower lobe. [2114-3-7] 06:15PM BLOOD Glucose-159* UreaN-22* Creat-1.4* Na-141 K-4.8 Cl-106 HCO3-23 AnGap-17 [2114-3-7] 06:15PM BLOOD PT-13.0 PTT-30.3 INR(PT)-1.1 [2114-3-7] 06:15PM BLOOD CK(CPK)-54 [2114-3-7] 06:15PM BLOOD cTropnT-<0.01 [2114-3-7] 09:59PM BLOOD Type-ART Rates-/16 Tidal V-550 PEEP-5 FiO2-100 pO2-108* pCO2-33* pH-7.43 calTCO2-23 Base XS-0 AADO2-572 REQ O2-94 -ASSIST/CON Intubat-INTUBATED Brief Hospital Course: 75 year old male with a history of TBI, GI bleed in [2113], CKI, prostate cancer, and recent discharge from [Hospital1 18] on [2114-2-14] for aspiration pneumonia, now admitted for respiratory distress associated with multiple pulmonary emboli. # Multiple pulmonary emboli: Patient with multiple pulmonary emboli likely secondary to immobility and malignancy. He was admitted to the ICU having already been intubated at an OSH due to respiratory failure despite his HCP's wishes that the patient not be intubated or resuscitated. He remained hemodynamically stable and was placed on Lovenox for treatment of his pulmonary emboli, but following discussion with the primary team, the HCP decided to extubate the patient and to provide only comfort measures if the patient's respiratory status began to deteriorate. The patient was extubated and placed on Morphine for comfort. He passed away early the next day. His HCP gave consent for an autopsy. # Fever: Patient with fever thought to be secondary to pulmonary emboli, but given his history of recent hospitalization for aspiration PNA, blood, sputum, and urine cultures were sent to rule out an infectious etiology. Active surveillance for infection was stopped after discussion with the patient's caregiver. # Chronic Renal Insufficiency: Not an active issue. Patient's creatinine on admission was noted to be 1.4 which was at patient's [Date Range 5348] of 1.3-1.7. Medications on Admission: Lyrica Simvastatin Omeprazole Metoprolol Tartrate Folic Acid Flomax Docusate Sodium Ferrous Sulfate Discharge Disposition: Expired Discharge Diagnosis: pulmonary embolus respiratory failure Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "415.19", "280.9", "585.6", "V10.46", "788.30", "426.3", "403.91", "518.0", "518.81", "438.20" ]	icd9cm	[ [ [] ] ]	[ "96.71" ]	icd9pcs	[ [ [] ] ]	5983, 5992	4388, 5832	358, 370	6073, 6082	3286, 4365	6134, 6276	2794, 2799				6013, 6052		5858, 5960			6106, 6111									2814, 3267																								281, 320				2012, 2032						398, 1994															2054, 2478	2494, 2778
48,601	156,646	44741	Discharge summary	report	Admission Date: [2189-2-24] Discharge Date: [2189-2-27] Date of Birth: [2138-9-25] Sex: M Service: UROLOGY Allergies: Penicillins Attending:[First Name3 (LF) 6736] Chief Complaint: AUS Major Surgical or Invasive Procedure: revision of AUS Brief Hospital Course: Patient was admitted to the Urology service after procedure. He was transferred from the PACU to the ICU for concerns of desaturation while sleeping secondary to OSA and was placed on BIPAP. He was transferred to the floor on POD 1 in stable condition on CPAP. He had a suprapubic tube in place that was draining well and he remained afebrile throughout his hospital stay. He was seen by physical therapy who cleared him for discharge home. Discharge Medications: 1. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed. 2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): use while taking narcotics. Disp:60 Capsule(s) Refills:0 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Varenicline Oral 7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H () as needed. Disp:30 Tablet(s) Refills:0 8. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 1 weeks. Disp:28 Capsule(s) Refills:0 Discharge Disposition: Home with Service Discharge Diagnosis: revision of AUS Discharge Condition: stable Discharge Instructions: - resume medications - leave suprapubic tube to gravity - followup with Dr. [Last Name (STitle) ] - return to emergency room for fevers/chills or other concerns Followup Instructions: 2 weeks Completed by:[2189-2-27]	[ "518.5", "996.39", "278.01", "305.1", "E878.4", "401.9", "E929.3", "327.26", "327.23", "V45.4", "344.61", "V44.59", "907.2", "344.1" ]	icd9cm	[ [ [] ] ]	[ "58.93", "59.94" ]	icd9pcs	[ [ [] ] ]	1509, 1528	315, 757	275, 292	1587, 1595		1811, 1849			780, 1486		1549, 1566					1619, 1788																																	232, 237
59,039	192,936	42169	Discharge summary	report	Admission Date: [2119-11-9] Discharge Date: [2119-12-16] Date of Birth: [2054-8-2] Sex: F Service: MEDICINE Allergies: Penicillins / Iodine / Quinine / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 99] Chief Complaint: cholecystitis Major Surgical or Invasive Procedure: ERCP percutaneous biliary drain placement History of Present Illness: 65 yo F with pmhx significant for MDS, tonsillar CA (last CTX 4yrs ago) and recently diagnosed cholelithiasis who was transferred from OSH [2119-11-9] after presenting with septic shock and found to have labs remarkable for AST 248, ALT 63, tbili 5.3, direct 3.3, WBC 11.1. RUQ U/S showed GB wall thickening and pericholecystic fluid that could indicate cholecystitis; cholithiasis present, however no intra- or extra-hepatic biliary dilation and no choledocholithiasis identified. Patient required pressors and was intubated in anticipation for ERCP. ERCP was performed [2119-11-9] which showed only small amount of sludge, no pus; stent was placed. On [2119-11-10] a percutaneous cholecystostomy was placed by IR. Initially good drainage via perc chole however yesterday noted to be draining ascitic fluid. Patient had a CT a/p on [2119-11-12] to r/o RP bleed due to hematocrit drop which was negative for bleed however did show that perc chole drain was in atypical position. IR evaluated imaging and determined that drain has been dislodged. Drain pulled on [2119-11-13]. New drain not placed as would be difficult per IR now that gall bladder decompressed. Patient also with abdominal pain attributed to bile leak. Bilirubin had improved but then began to increase again over past two days, now 5. Given overall concern for persistent cholecystitis plan is for HIDA in the am. Patient has been on empiric broad spectrum antibiotics with vancomycin/cefepime/flagyl. Of note, LFTs have been elevated AST/ALT ratio > 2. Hepatology consulted [2119-11-12], thought likely alcoholic hepatitis worsened by sepsis (significant heavy etoh history, currently drinks 3x per day). Concern for hep B/C given history of multiple blood transfusions and IVIG for MDS. Viral hep serologies, [Doctor First Name ], AMA, AntiSm Ab pending. Also with esophageal stricture as seen on ERCP with possible aspiraton pneumonitis. Failed bedside swallow, currently NPO, awaiting video swallow. Currently patient has no complaints. Endorses vague RUQ discomfort. No nausea, vomiting or diarrhea. Denies any sob or cp. Mild cough. Past Medical History: - tonsillar CA s/p XRT and CTX (last Rx 4 years ago, in remission) - MDS: on procrit and IVIG infusions - GERD - hypothyroidism - s/p CVA in [2107] - HTN - autoimmune demyelinating polyneuropathy Social History: Lives with daughter, retired high school english teacher - Tobacco: quit 14 years ago, 20pack year hx - Alcohol: social use - Illicits: denies Family History: mother: depression, DM, HTN father: died of aneurysm Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera icteric, dry oral mucosa, oropharynx clear Neck: supple, distension of external jugular vein Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: tachycardia, regular S1 S2 no m/r/g Abdomen: soft, non-distended, bowel sounds present, pain to deep palpation in RUQ Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN II- XII intact, strenth grossly normal, intact to light sensation; left upper extremity intention tremor, cerebellar exam intact by FNF Pertinent Results: Labs on admission: [2119-11-9] 03:55AM WBC-12.7* RBC-2.77* HGB-10.2* HCT-28.7* MCV-104* MCH-36.8* MCHC-35.6* RDW-13.8 [2119-11-9] 03:55AM NEUTS-82* BANDS-13* LYMPHS-1* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-2* MYELOS-0 [2119-11-9] 03:55AM PT-17.3* PTT-39.6* INR(PT)-1.5* [2119-11-9] 03:55AM GLUCOSE-103* UREA N-27* CREAT-2.2* SODIUM-133 POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-17* ANION GAP-19 [2119-11-9] 03:55AM ALT(SGPT)-70* AST(SGOT)-244* ALK PHOS-131* TOT BILI-4.8* DIR BILI-4.1* INDIR BIL-0.7 [2119-11-9] 04:02AM LACTATE-2.2* [2119-11-9] 04:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2119-11-9] 11:15AM PT-19.8* PTT-43.9* INR(PT)-1.8* [2119-11-9] 11:15AM FIBRINOGE-298 RUQ U/S: [2119-11-9] 1. Gallbladder wall thickening and pericholecystic fluid, in the setting of cholelithiasis, representing acute cholecystitis. 2. No choledocholithiasis, or intra- or extrahepatic biliary ductal dilatation. CXR: [2119-11-9] No focal opacity to suggest pneumonia is seen. No pleural effusion or pneumothorax is present. Vascular congestion in the lungs and mediastinum is mild, and the lungs are on the verge of edema. The heart size is normal. A right-sided port-a-cath is in place with tip reaching the right atrium CT Abdomen/ pelvis: [2119-11-10] 1. Bilateral simple pleural effusions with atelectasis. 2. Cholecystostomy tube appears in an atypical position; a call to the team confirmed that it was draining large amount of bilious fluid; if clinical concern for it becoming displaced increases (ie, drainage ceases), a tube check should be considered. This finding was discussed with [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 91461] at 19:30 on [2119-11-12] by [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 11623] over the phone. 3. Small-to-moderate intraabdominal fluid is simple in nature and tracks along paracolic gutters and into the pelvis. No retroperitoneal fluid collections. 4. Age indeterminate compression deformities of the L2 and L3 vertebral bodies. 5. Cholelithiasis. Micro: bile cx: [2119-11-10] enterococcus SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ <=2 S PENICILLIN G----------<=0.12 S VANCOMYCIN------------ <=0.5 S Brief Hospital Course: 65F w/ hx tonsillar CA, last chemo 4 years ago, p/w septic shock secondary to presumed cholangitis. . # Septic Shock: Presented with hypotension requiring pressors. Presumptive source cholangitis based on presentation of fever, jaundice and RUQ pain with ultrasound showing gallbladder thickening with pericystic fluid. Initially, given PCN allergy, covered with vanc/cipro/flagyl. No evidence of other focal infection such as PNA, UTI initially, though she later had focal infiltrate and was broadened to vanc/cefepime/flagyl. For cholangitis, had ERCP, which did not show definitive source; later had PTC placement given diverticulum and possible etiology of infection. PTC drained copious bile following placement, however then dislodged so it was removed. Following removal, pt noted to have increasing abdominal pain, increasing white count though did not meet SIRS criteria. She was continued on vanc/cefepime/flagyl with stablization in her WBC, though total bilirubin continued to rise. Surgery did not feel cholecystectomy was indicated because repeat imaging did not suggest cholecystitis. ERCP likewise did not feel repeat ERCP was indicated. Pt's vanc/cefepime/flagyl were discontinued on [11-20] due to absence of signs or symptoms of infection. The patient did not have any clinical evidence of cholangitis. At this time the patient continued to have evidence of severe sepsis. She continued to have a leukocytosis and intermittently slight fevers throughout her course. Patient was treated with 4 ventilator associated pneumonia. She was also found to have [Female First Name (un) 564], none over 10 cc, growing in her sputum, urine, bile. The patient was started on IV micafungin. The patient continued to require IV pressors throughout her entire hospital course and medical ICU. We were unable to successfully wean the patient off her pressor support. This most likely was a combination of her liver failure as well as continued septic shock. Ultimately this was one of the main cause of her death. During her stay with her complex infectious disease course we obtained infectious disease consultation and they felt the patient for her medical ICU stay. . # Elevated bilirubin/transaminases: Initially fit with picture of cholangitis; however, in the setting of rising Tbili despite PTC drain, hepatology was consulted. They felt she may have component of alcoholic hepatitis in setting of long term continued alcohol use. Viral serologies, [Doctor First Name ], AMA, AntiSm Ab were checked. [Doctor First Name ] positive with titer 1:40, AMA negative, AntiSm antibody negative. HCV also negative. HbsAg negative, HBsAb positive, HBcAb positive suggesting previous infection. Hepatitis A positive but IgM negative. Suspect that much of her presentation now is attributable almost entirely to alcoholic hepatitis. Several other serological tests are pending for auto-immune or other causes of hepatitis. Pt does not have cirrhosis by ultrasound imaging, which shows essentially normal liver structure. After spending some time in the medical ICU the hepatology service question whether this could also be a biliary disease process as well. A percutaneous cholecystostomy tube was placed a second time by interventional radiology. The Gram stain of the bile was significant for [Female First Name (un) ], non-albican species. Patient continued to have liver failure with significant elevations in her total bilirubin. She remained encephalopathic throughout her hospital stay. The hepatology service felt that this was a nonreversible end-stage liver disease with a extremely poor prognosis. They did not believe she was a candidate for liver transplantation. This was ultimately listed as her primary cause of death. # elevated creatinine: Admitted with Cr of 2.2 from unknown baseline (stable from OSH): likely representing acute on chronic kidney disease. [Month (only) 116] represent ARF from septic shock, resolved to Cr 1.0, however elevated again in setting of diuresis to 1.4. Pt is total volume positive 14 L for hospital stay, though FeUrea 19% suggesting intravascularly depleted, likely [2-22] CHF. Patient remained in the near throughout her hospital stay and medical ICU. She required both hemodialysis and CVVH throughout the stay. The renal service was following the patient and provided recommendations for her dialysis treatments. . # Anemia: pt required 1 unit PRBC on [11-11]. CT a/p was done to eval for RP bleed in setting of intra-abdominal procedures above. CT was negative. anemia otherwise stable and felt to be [2-22] MDS. The patient remains somewhat anemic throughout her stay and there was no clear source for her anemia. Most likely secondary to either marrow suppression or anemia chronic disease. Patient required multiple blood transfusions throughout her stay for a slow down-trending hematocrit. . # thrombocytopenia: stable, likely [2-22] MDS. The patient continued to have thrombocytopenia throughout her stay. There is no significant bleeding episodes. #Altered mental status: Patient had significant altered mental status most likely was secondary to hepatic encephalopathy. However she was noted to have some seizure-like activity towards the end of her hospital stay. An EEG was performed and showed evidence of some ictal activity. The patient was started on Keppra with some minimal improvement in her mental status. #Supraventricular tachycardia: The patient had multiple episodes of a superventricular tachycardia most likely AV nodal reentrant tachycardia. The patient was sensitive to carotid massage. She required both IVP to blockade and calcium channel blockers for rate control if carotid massage did not lower her heart rate. During most of these episodes she remained hemodynamically stable. #Nutrition: The patient was started on tube feeding shortly after arriving in the medical ICU. We continued his to be throughout her stay. nutrition was following and provide daily recommendations for nutrition changes as needed. #Respiratory failure: The patient had significant respiratory problems her stay. She required a period of intubation. She was eventually extubated but remained somewhat hypoxic and required high oxygen requirements most of the time she was in the medical ICU. Her respiratory distress and hypoxia was most likely due to episodes of pulmonary edema as well as a suspected ventilator associated pneumonia. The patient's fluid status was maintained by hemodialysis and she received a treatment of antibiotics for ventilator associated pneumonia. #Goals of care: The patient's daughter was her health care proxy. Multiple family meeting were held with the health care proxy discussing the patient's clinical status. Throughout most of the family meetings the daughter maintained that she wanted to continue full treatment of the patient. On the morning of [12-16] another family meeting was held with the daughter. At that time the daughter agreed that the patient should be made comfort measures only. The patient was weaned from the pressors and given IV analgesia for comfort. The patient expired shortly after making her CMO. Medications on Admission: propranolol 300mg daily irbesartan 300mg daily omeprazole 20mg daily vitamin D/ calcium folic acid 1mg daily levothyroxine 75mg magnesium 400mg [Hospital1 ] MVI Discharge Disposition: Expired Discharge Diagnosis: Liver failure septic shock Discharge Condition: Expired	[ "997.31", "V66.7", "E849.8", "E879.2", "562.00", "799.02", "305.01", "E849.7", "571.1", "V10.02", "238.75", "785.52", "357.81", "584.9", "244.9", "038.9", "570", "E879.8", "518.81", "041.04", "285.29", "276.2", "571.2", "576.2", "575.0", "V49.86", "585.6", "112.89", "995.92" ]	icd9cm	[ [ [] ] ]	[ "96.72", "39.95", "54.91", "38.93", "38.95", "86.07", "51.01", "50.13", "51.87", "96.04", "38.97", "96.71", "38.91" ]	icd9pcs	[ [ [] ] ]	13487, 13496	6099, 11159	337, 380	13566, 13576	3595, 3600		2949, 3004				13517, 13545		13297, 13464												3019, 3576																								284, 299										408, 2548									3614, 6076		11174, 13271				2570, 2772	2788, 2933
12,697	163,616	3175	Discharge summary	report	Admission Date: [2160-3-13] Discharge Date: [2160-4-11] Date of Birth: [2134-3-11] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 26 year-old gentleman with a history of a intraventricular hemorrhage at birth and a VP shunt placed two weeks after birth. The patient did well until six years ago when he required several revisions of the shunt and developed an infection. He finally did well and was well until two weeks prior to admission when he required another shunt revision due to severe headaches. The patient had a shunt revision and was discharged to home. The patient returned on [3-13] with repeated headache. Head CT at that time showed hydrocephalus and the patient was admitted and taken to the Operating Room for a shunt revision. The shunt was removed and the patient had a ventriculostomy drain placed and transferred to the Intensive Care Unit for close monitoring. ALLERGIES: Vancomycin. MEDICATIONS: Dilantin. PHYSICAL EXAMINATION: Vital signs on admission blood pressure 100 to 130/60 to 70. Heart rate was in the 70s. Sats 95 to 96% on room air. His ICP postop was 2 to 3. He was awake, alert and oriented times three with no drift, smile symmetric. Pupils are equal, round and reactive to light. Extraocular movements intact. Moving all extremities. His motor strength was 5 out of 5 in all muscle groups. HOSPITAL COURSE: He was monitored in the Intensive Care Unit for several days with keeping the cerebral spinal fluid drainage at 10 to 15 cc an hour. He had several cerebral spinal fluid cultures sent. One culture was positive from the [3-13] and that was thought possibly to be contamination. The patient was seen by the Infectious Disease Service who recommended continued antibiotic coverage. The patient remained in the Intensive Care Unit until [2160-3-21] and he was taken back to the Operating Room for excisional biopsy of a posterior fossa lesion thought to be associated with infection with the VP shunt. The patient tolerated te procedure well and there were no complications. He was monitored in the Intensive Care Unit overnight. He was awake, alert and oriented times three complaining of just a little bit of incisional pain, moving all extremities with good strength. Visual fields were full. On [2160-3-23] the patient was transferred to the regular floor where he remained neurologically stable with a ventriculostomy drain in place with a valve to allow him to be on the floor. The patient continued to be followed by the Infectious Disease Service awaiting results of the pathology of this lesion. The patient's vital signs remained stable. He remained afebrile and neurologically intact. The pathology of the lesion turned out to be pleomorhic xanthoastrocytoma . He continued on prophylactic antibiotics while the ventricular drain was still in place. He was taken back to the Operating Room on [2160-4-8] for a shunt revision. He tolerated that procedure well. His incisions were clean, dry and intact. His abdomen was soft, nontender, nondistended. He has positive bowel sounds. He is tolerating a regular diet. He is discharged to home on [2160-4-11] with follow up in the Brain [Hospital 341] Clinic in two weeks and follow up staple removal on postop day number ten. MEDICATIONS ON DISCHARGE: 1. Dilantin 400 mg once a day. 2. Percocet one to two tabs po q 4 hours prn for headache. CONDITION ON DISCHARGE: Stable. [First Name11 (Name Pattern1) 125] [Last Name (NamePattern4) 342], M.D. [MD Number(1) 343] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2160-4-11] 08:31 T: [2160-4-11] 09:22 JOB#: [Job Number 14948]	[ "191.2", "E878.8", "996.2", "331.4", "780.39" ]	icd9cm	[ [ [] ] ]	[ "02.42", "01.59", "01.02" ]	icd9pcs	[ [ [] ] ]												3361, 3454		1415, 3335																								1013, 1397																					160, 990																	3479, 3769

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